
Qass. 
Book. 



COPYRIGHT DEPOSIT 



ON THE 



DISEASES 



INFANTS AND CHILDREN. 



BY 



FLEETWOOD CHURCHILL, M.D., M.R.I.A., 

HON-. FELLOW OF THE COLLEGE OF PHYSICIANS, IRELAND J 
HON. MEMBER OF THE PHILADELPHIA MEDICAL SOCIETY, ETC. ETC. 



SECOND AMERICAN EDITION, 
ENLARGED AND REVISED BY THE AUTHOR. 



EDITED WITH ADDITIONS, 



WILLIAM Y. KEATING, M.D., A.M., 

PHYSICIAN TO ST. JOSEPH'S HOSPITAL; LECTURER ON OBSTETRICS AND DISEASES OF WOMEN 

IN THE PHILADELPHIA MEDICAL ASSOCIATION ; PHYSICIAN TO ST. JOSEPH'S ASYLUM 

FOR ORPHANS ; FELLOW OF THE COLLEGE OF PHYSICIANS ; MEMBER OF 

THE AMERICAN PHILOSOPHICAL SOCIETY, ETC. ETC. ETC. 




PHILADELPHIA: 

B L A N CHARD AND LEA. 

1856. 



to 



Entered according to the Act of Congress, in tlie year 1856, by 

BLANCHARD AND LEA, 

in the Clerk's Office of the District Conrt for the Eastern District of Pennsylvania. 



PHILADELPHIA : 
T. K. AND P. G. COLLINS, PRINTERS. 



TO 

ROBERT M. HUSTON, M. D., 

ISAAC HAYS, M. D., 

AND 

GEORGE- SHATTXJCK, Jun., M. D., 
THIS WORK 

IS DEDICATED, 

AS AN 
EXPRESSION OF THE HIGHEST ESTEEM 

FOE THEIR 

PERSONAL FRIENDSHIP AND PROFESSIONAL ATTAINMENTS. 



PKEEACE 



AMERICAN EDITOR. 



The American Publishers having confided to my care the Author's 
revised copy of the present work, I have bestowed every attention in 
the revision of the press to secure accuracy. The difficulty of this has 
been much enhanced by the fact that a large portion of the work was in 
MS. The extent of the additions made by Dr. Churchill is manifested 
by the increase of a hundred pages in the volume, notwithstanding an 
enlargement in the size of the page ; and the special reference which 
he has made to American authorities, with a view of adapting the 
work to the wants of American practitioners, has rendered unnecessary 
many additions from me. Such as I have considered advisable have 
been generally introduced in brackets, to distinguish them from the text. 

In its present improved form, the work can hardly fail to maintain 
the high reputation previously acquired. 

Philadelphia, 111 South 4th Street, 
July, 1856. 



AUTHOR'S PREFACE 



SECOND AMERICAN EDITION 



In preparing this Edition for the press, I have endeavored carefully 
to add all the information we have derived from recent researches. I 
have gone over every paragraph, with a view to correct any inaccuracy 
and to remedy any indefiniteness of expression. I have cautiously 
weighed every suggestion made by those who have reviewed the work, 
and where these seemed to me to be correct, I have adopted them, and 
made the requisite alterations, and I have added several entire new 
chapters, as well as portions of chapters, so that I hope that the 
work may be deemed more worthy of the kindness it has received at 
the hands of my American brethren, to whom once more I desire to 
offer my sincere thanks for the welcome they have accorded to this, 
as well as my other volumes. 

15 Stephen's Green, North Dublin, 
February, 1856. 



PREFACE 



It is with much gratification that I acknowledge this volume to owe 
its existence to the solicitations of my excellent American publishers. 
After making a considerable collection of works on Diseases of Chil- 
dren, I had laid them aside, hopeless of accomplishing the task of 
writing the work I had contemplated ; but it was impossible to decline 
an invitation so flattering, from a country which had shown so much 
indulgence to my former works. 

I have, therefore, in such leisure as I have been able to command 
during the last three years, written this volume, not as the exponent of 
my own experience alone, but as embracing the information recorded by 
all the authors within my reach, of which I have freely availed myself ; 
and, if it prove useful and acceptable to my American brethren, I shall 
be richly repaid. 

There is one portion of the history of infantile diseases which has 
hardly received the attention it deserves. I allude to the secondary 
diseases ; those which occur in the course of other disorders, and are, 
in some intimate but obscure way, connected with them almost in the 
relation of cause and effect. They complicate, and often confuse the 
symptoms of the primary affection, always seriously increase its danger, 
and often render it hopeless of cure. Their early detection, or what is 
far better, their anticipation and prevention, forms a very important 
part of the physician's duty; and I have endeavored, as far as I could, 
to facilitate this object by carefully noticing both the complications to 
which each disease is liable, and the primary disorders to which it may 
become secondary. 

Another point of great importance, in the treatment of the diseases 
of children, is to observe and remember the prevailing epidemic, or the 
atmospheric constitution of the time. All diseases are more or less 
thus modified, and with children this is very remarkable, not merely as 
regards the symptoms, but the treatment also. Without a careful 
attention to this matter, we shall often aggravate, instead of relieving 
the condition of the child. 



X PREFACE. 

I have found it extremely difficult to lay down minute and specific 
plans of treatment for individual cases, or for the various modifications 
of disease ; and, I fear, in this respect, my book may be thought defi- 
cient. I have, however, always indicated the principles, which must 
guide us in the management of the disorder ; and I have preferred 
leaving their adaptation to the sagacity and judgment of the practi- 
tioner. 

I have sought information wherever I had reason to believe it was to 
be found ; I have consulted all the authorities within my reach, and 
have carefully referred to those from whom I have quoted, but yet I 
fear that many faults, both of omission and commission, will be observ- 
ed. In these, I must request the indulgence of the reader, who, I hope, 
will bear in mind, that the work has been written in the midst of the 
distractions of professional business, or at hours which are usually 
devoted to rest. 

F. CHURCHILL. 



137 Stephen's Green, Dublin, October, 1849. 



CONTENTS. 



PART 1. 

ON THE MANAGEMENT OF INFANCY AND CHILDHOOD. 
CHAPTER I. 

PAGE 
PRELIMINARY OBSERVATIONS ON THE MANAGEMENT OF INFANCY AND CHILDHOOD. 15 

CHAPTER II. 

MANAGEMENT OF THE INFANT AT BIRTH. . . .32 



Dress 



Sleep 
Medicine 



CHAPTER III. 

THE FOOD OF INFANCY AND CHILDHOOD. 

CHAPTER IV. 

CLEANLINESS. 

CHAPTER V. 

AIR AND EXERCISE. 



37 



52 



PART II. 

THE DISEASES OF INFANCY AND CHILDHOOD. 

SECTION I. 
DISEASES OF THE CEREBROSPINAL SYSTEM. 



CHAPTER I. 




INTRA-UTERINE OR CONGENITAL DISEASES. 




Convulsions ....... 

Hydrocephalus ....... 

Absence of Brain or Skull ..... 

Hernia Cerebri. — Encephalocele .... 

Spina Bifida. — Hydrorachitis ..... 


. 71 
. 71 

. 72 

. 73 

75 



CONTENTS. 



CHAPTER II. 

PAGE 

CEPHALHEMATOMA. — FRACTURES OF THE CRANIUM. . . 82 

Sub-aponeurotic Cephalhematoma . . . . . .84 

Sub-pericranial Cephalhematoma . . . . . .85 

Sub-cranial Cephalgematoma . . . . . .87 

CHAPTER III. 

IRRITATION OF THE NERVOUS SYSTEM. — TRISMUS NASCENTIUM. 

Nervous Irritation ........ 90 

Trismus Nascentium. — Nine-day fits . . . . . .94 

CHAPTER IV. 

CHOREA. — ST. VITUS' DANCE. . . . 102 

CHAPTER V. 

CONVULSIONS. . . . .114 

CHAPTER VI. 

ACUTE MENINGITIS. — ACUTE ARACHNITIS. — ACUTE HYDROCEPHALUS. . 134 

CHAPTER VII. 

CHRONIC HYDROCEPHALUS. . . . 1G0 

CHAPTER VIII. 

INFLAMMATION OF THE BRAIN. 

Encephalitis ......... 176 

Hypertrophy and Induration of the Brain ..... 178 

Ramollissement, or Softening ....... 183 

Abscess of the Brain ........ 184 

CHAPTER IX. 

TUMORS OR TUBERCLES OF THE BRAIN AND SPINAL MARROW. . 186 

CHAPTER X. 

CONGESTION AND APOPLEXY OF THE BRAIN. . . 195 

CHAPTER XI. 

PARALYSIS. .... 202 



SECTION II. 
DISEASES OF THE RESPIRATORY SYSTEM. 

CHAPTER I. 

INTRA-UTERINE DISEASES. . . . 213 

Coryza . . . . . . . . . .213 

Epistaxis ......... 215 



CONTENTS. Xlll 

CHAPTER II. 

PAGE 
SPASM OF THE GLOTTIS. — THYMIC ASTHMA. — LARYNGISMUS STRIDULUS. . 216 

CHAPTER III. 

PERTUSSIS. — HOOPING-COUGH. . . . 229 

CHAPTER IV. 

CROUP. — CYNANCHE TRACHEALIS. . . . 259 

CHAPTER V. 

ATELECTASIS PULMONUM. .... 292 

CHAPTERVI. 

BRONCHITIS. .... 300 

CHAPTER VII. 

INFLAMMATION OF THE LUNGS. PNEUMONIA. . .315 

CHAPTER VIII. 

PLEURISY. — PLEURITIS. .... 341 

CHAPTER IX. 

PULMONARY PHTHISIS. .... 356 



SECTION III. 
DISEASES OF THE HEART. 

CHAPTER I. 

MALFORMATIONS. — INTRA-UTERINE DISEASES. . . 376 

Cyanosis .......... 377 

CHAPTER II. 

INFLAMMATION OF THE PERICARDIUM.— PERICARDITIS. . „ 385 

CHAPTER III. 

INFLAMMATION OF THE LINING MEMBRANE OF THE HEART. — ENDOCARDITIS. 397 



SECTION IT. 

DISEASES OF THE DIGESTIVE SYSTEM. 

CHAPTER I. 

INTRA-UTERINE DISEASES.— CONGENITAL MALFORMATIONS. . . 405 



XIV CONTENTS. 

CHAPTER II. 

PAGE 
DENTITION. ..... 416 

CHAPTER III. 

INFLAMMATION OF THE MOUTH. — ERYTHEMATOUS STOMATITIS. . 426 

CHAPTER IV. 

MUGUET. PSEUDO-MEMBRANOUS STOMATITIS. . . 427 

CHAPTER V. 

APHTHAE. — THRUSH. — FOLLICULAR STOMATITIS. . . 437 

CHAPTER VI. 

ULCERATED SORE MOUTH. — ULCERATED STOMATITIS. . . 442 

CHAPTER VII. 

GANGRENE OF THE MOUTH. — CANCRUM ORIS. — GANGRENOUS STOMATITIS. . 446 

CHAPTER VIII. 

TONSILLITIS. — CYNANCHE TONSILLARIS. — QUINSY. . . 460 

CHAPTER IX. 

PAROTITIS.— C FN ANCHE PAROTIDEA. — MUMPS. . . 464 

CHAPTER X. 

PSEUDO-MEMBRANOUS PHARYNGITIS. — DIPHTHERITE. — ANGINA PSEUDO-MEMBRANOSA. 468 

CHAPTER XI. 

PUTRID SORE THROAT. — GANGRENOUS ULCERATION OF THE PHARYNX. . 475 

CHAPTER XII. 

ABSCESS BETWEEN THE PHARYNX AND THE SPINE. . . 481 

CHAPTER XIII. 

DISEASES OF THE STOMACH. . . . 483 

CHAPTER XIV. 

INDIGESTION. — VOMITING. — WEANING BRASH. . . 488 

CHAPTER XV. 

GASTRITIS. — INFLAMMATION AND SOFTENING OF THE STOMACH. . 496 



CONTENTS. 



CHAPTER X'VI. 

PAGE 
DIARRHOEA. .... 503 

Cholera Infantum ........ 506 

Enteritis .......... 509 

CHAPTER XVII. 

DVSENTERY. — COLITIS. .... 521 

CHAPTER XVIII. 

HELMINTHIASIS. INTESTINAL WORMS. . . . 530 

CHAPTER XIX. 

I. JAUNDICE. II. ENLARGEMENT OF THE LIVER, SPLEEN, ETC. . 538 

CHAPTER XX. 

TABES MESENTERICA. .... 545 

CHAPTER XXI. 

PERITONITIS. .... 554 



SECTION V. 
DISEASES OF THE SKIN. 

CHAPTER I. 

STROPHULUS. — PRURIGO. — PTTRIASIS. — ROSEOLA. 

Strophulus, or Red Gum . . . . ... . 567 

Prurigo .......... 568 

Pityriasis . . . . . . . . . 569 

Roseola . . . . . . . . . . 570 

CHAPTER II. 

HERPES. ECZEMA. — RUPIA. 

Herpes . . . . . . . . . .571 

Eczema .......... 572 

Rupia .......... 574 

CHAPTER III. 



Impetigo . . . . . . . . .576 

Porrigo, or Scald Head ........ 578 

Porrigo Scutulata, or Ringworm of the Scalp ..... 578 

Porrigo Favosa . . . . . . . . .583 



CONTENTS. 

SECTION VI. 
ERUPTIVE FEVERS. 

CHAPTER I. 

PAGE 
MEASLES. RUBEOLA. — MORBILLI. . . . 589 

CHAPTER II. 

SCARLET FEVER. — SCARLATINA. . . . 610 

CHAPTER III. 

VARICELLA. — CHICKEN-POX.— SWINE-POX. . . 645 

CHAPTER IV. 

SMALLPOX. VARIOLA. PETITE VEROLE, . . 649 

CHAPTER V. 

VACCINIA.— COWPOX. .... 668 

CHAPTER VI. 

(EDEMA OF THE CELLULAR TISSUE. — SCLEROMA. . . 677 



SECTION VII. 

FEVERS. 
CHAPTER I. 

INFANTILE REMITTENT FEVER. . . . 684 

CHAPTER II. 

TYPHOID FEVER. .... 695 



SECTION VIII. 

INFANTILE SYPHILIS. . . .705 



ON 



THE DISEASES OF CHILDREN 



*c. ore <yc. 



PART I. 



ON THE 

MANAGEMENT OE INFANCY AND CHILDHOOD. 



CHAPTER I. 

PRELIMINARY OBSERVATIONS. 

1. A very limited acquaintance with statistics, or even a moderate 
experience, is quite sufficient to convince us of the high degree of mor- 
tality which prevails among infants and children : literally, they spring 
up and are cut down like flowers of the field. 

This mortality commences before the birth of the infant : from vari- 
ous causes no inconsiderable proportion of those ushered into the world 
are stillborn. M. Quetelet, in his very learned and able work, thus 
states, that in the principal cities of Europe 1 the mean proportion of 
stillborn children is one in every twenty-tivo births; and the number is 
three times greater among illegitimate than among legitimate children. 

2. The same author gives a carefully compiled table of the mortality 
of different ages in Belgium, which shows that of the infants born alive, 
one-tenth died within a month — a mortality equal to that between the 
ages of 7 and 24 years. By the fifth year, nearly one-half the number 
of children had died. 2 

3. In Prussia, during the interval from 1820 to 1828, the deaths in 
the first year were in the ratio of 26.944 to 100.000. In France, in 
1802, it amounted to 21.457; in Amsterdam to 22.735, from 1818 to 
1829 ; in Sweden, to 22.453, from 1821 to 1825. 

From the First Report of the Registrar-General of England, it ap- 
pears that more than one-third of the total deaths in England and Wales 
occur tinder tivo years of age ; the proportion being 42.54 per 1000 of 
the deaths registered : and two out of every nine infants entering upon 
life die within the first year. " Assuming seventy years as the natural 
term of life, we may form some faint conception, from the preceding 
facts, how many elements of destruction must still be left in full activity, 
when, as is the case in England, one-third of the race is cut off within 
the first two years of existence." 3 

1 Sur l'Homme et le Developpement de ses Facultes, &c, vol. i. p. 121. 

2 lb., vol. i. p. 167. 

3 Combe on the Management of Infancy, p. 10. 



20 ON THE MANAGEMENT OP 

In the Second Report I find that the total number of births was 
480,090— of deaths, 331,007 ; of the latter, 72,30-1 were under one 
year, and 130,695 under five years of age. In the Third Report, the 
births were 501,589 — the deaths, 350,101 ; of those under one year, 
76,328 ; under five, 141,747. In the Fourth Report, the births were 
504,543,— the deaths, 355,622 ; of those under one year, 75,507 ; 
and under five, 140,089. In the Fifth Report, the births were 492,574, 
— the deaths, 343,847 ; of those under one year, 74,210 ; and under 
five, 133,583. In the Sixth Report, the births were 517,739,— the 
deaths, 349,519 ; of those under one year, 78,704 ; and under five, 
139,035. In the Sixth annual Report, will be found abstracts from 
foreign Reports, all showing the great mortality in the earlier periods of 
life. 

In my friend Mr. Wilde's admirable Report in the Census of Ireland, 
he states that, in the ten years ending June 6, 1841, the total number 
of deaths in the city of Dublin were 66,722, of which 10,553 occurred 
under one year, and 13,037 between one and five years of age. 

Dr. Combe has extracted the following statistics from the Liverpool 
Albion of April 1, 1839. The deaths during the year 1838 amounted 
to 6596, from which must be deducted forty-three still-births, leaving 
6553. Now at different periods of the first five years of life we find 
the following mortality : — 



Under 3 months 






792 deaths. 


Above 3 " 


and unde 


r 6 months, 


313 " 


" 6 " 


" 


9 " 


319 " 


" 9 " 


" 


12 " 


311 " 


" 1 year, 


" 


2 years, 


802 " 


« 2 " 


" 


3 " 


321 " 


" 3 « 


" 


4 " 


183 " 


" 4 " 


" 


5 " 


121 « 



3162 " 

4. So much for the mortality generally; if we inquire into details 
we find it always great, though varying, as, for example, between the 
children of the poor and those in comfortable circumstances; between 
the poor in towns and those in the country ; or between the poor in 
different towns, or in different parts of the country differing in hygienic 
conditions ; proving conclusively, that the mortality depends, to a certain 
extent, upon external circumstances, and also that it is in some measure 
under the control of good management. 

From Dr. Granville's tables of the mortality among the poor of 
London, we find that 458 in every 1000 children under two years of 
age died. 

From the First Report of the Registrar- General, already quoted, it 
appears that, in the mining parts of Staffordshire and Shropshire, in 
Leeds and its suburbs, and in Cambridgeshire, Huntingdonshire, and 
the lowland parts of Lincolnshire, the deaths of infants under one year 
have been more than 270 out of 1000 deaths at all ages ; while in the 
northern counties of England, in Wiltshire, Dorsetshire, and Devon- 
shire, in Herefordshire and Monmouthshire, and in Wales, the deaths 



INFANCY AND CHILDHOOD. 21 

at that age, out of 1000 of all ages, scarcely exceed 180. 1 Compare, 
again, Manchester, Salford, and their suburbs, where the number 
of deaths under two years of age was 429.98 per 1000, with West- 
moreland and Cumberland, where the proportion was only 276.35 per 
1000. 

In Mr. M'Clean's Visit to St. Kilda, he states that " eight out of every 
ten children die between the eighth and twelfth days of their existence ;" 
and this, he conceives, is mainly owing to the " filth in which they live, 
and the noxious effluvia of their homes." 

5. But there are more shocking evidences still of the result of bad 
accommodation and mismanagement. For example, Dr. Combe states 2 
that, " about a century ago, the workhouses of London presented the 
astounding result of twenty -three deaths in every twenty-four infants 
under the age of one year. For a long time this frightful devastation 
was allowed to go on, as beyond the reach of human remedy. But 
when at last an improved system of management was adopted, in con- 
sequence of a parliamenta^ inquiry having taken place, the proportion 
of deaths was speedily reduced from 2600 to 450 a year." 

6. Another illustration of the effects of management is afforded by 
the mortality in lying-in hospitals. Dr. Willan gives the following pro- 
portions : — 

From 1749 to 1758 1 in 15 children died. 
" 1759 to 1768 1 in 20 
< ; 1769 to 1778 1 in 42 
" 1779 to 1788 1 in 44 
" 1789 to 1798 1 in 77 

In the valuable paper of the late Dr. Joseph Clarke, 3 of this city, 
he mentions that, " at the conclusion of the year 1782, of 17,650 in- 
fants born alive in the Hospital, 2944 died within the first fortnight," 
that is, nearly every sixth child ; and that of these nineteen out of 
twenty died of nine-day fits. This Dr. Clark attributed to want of ade- 
quate ventilation, which he proceeded to remedy with great success, for 
of 8033 children born after a free circulation of air had been secured, 
only 419 died, that is, about 1 in 19i. 

This rate of mortality has continued to diminish, for we find in the 
admirable Report published by Dr. Collins, that during his residence 
" the total number of children born was 16,654 ; of these 284 died pre- 
vious to the mother leaving Hospital ; this is nearly in the proportion of 
one in 58|, which would be considered a moderate mortality under any 
circumstances ; however, when it is considered that this includes not 
only all the deaths that occurred in children born prematurely , and in 
twins, but also every instance ivhere the heart ever acted, or tvhere respira- 
tion ceased in a feiv seconds after birth, the proportion of deaths be- 
comes trifling indeed." 4 

7. Foundling hospitals exhibit another instance of the connection be- 
tween the management and the rate of mortality in children. In the 

1 Report, pp. 25, 44. 2 On the Management of Children, p. 14. 

3 Transactions of the Royal Irish Academy, vol. iii. Collins's Practical Treatise, p. 
514. 

4 Practical Treatise on Midwifery, p. 500. 



on 



ON THE MANAGEMENT OF 



Foundling Hospital of this city it appeared, on inquiry by Parliament, 
that of 10,272 children sent to the infirmary of the hospital during the 
twenty-one years ending in 1796, only forty-five recovered, a state- 
ment, as Dr. Hawkins observes, which at this moment seems incredible. 1 
A change of plan was made, wet nurses were employed, arid children 
sent to them in the country, and the results were- most beneficial. From 
June, 1805, to June, 1806, 2168 infants were taken into the house, 
and only 486 died there — a manifest improvement. 

In Vienna, in 1811, the mortality was 92 per cent. ; in Brussels, from 
1812 to 1817, it was 79 per cent. ; in Madrid, in 1817, it was 67 per 
cent. ; that is, three and four times greater than the average mortality 
in private life. About one-half of the foundlings of Paris and St. Pe- 
tersburg die during the first year, notwithstanding the care and atten- 
tion bestowed. 

8. Dr. Combe quotes an interesting illustration of the effects of im- 
proved management in the Orphan Asylum of Albany, U. S., " which 
was opened in the end of 1829, with about seventy children, but in 
which the average, up to August, 1836, subsequently amounted to 
eighty. During the first three years, when an imperfect mode of man- 
agement was in operation, from four to six children were constantly on 
the sick list, and sometimes more ; one or two assistant nurses were 
necessary ; a physician was in regular attendance twice or thrice a 
week, and the deaths amounted in all to between thirty and forty, or 
about one every month. At the end of this time an improved system 
of treatment was begun, and notwithstanding the disadvantages insepa- 
rable from the orphan state of the children, the results were in the 
highest degree satisfactory." " The nursery was soon entirely vacated, 
and the services of the nurse and physician no longer needed ; and 
for more than two years no case of sickness or death took place. In 
the succeeding twelve years there were three deaths, but they were 
new inmates, and diseased when they were received, and two of them 
were idiots." 2 

9. In the last edition of Dr. Underwood's book, are given the results of 
an inquiry into the mortality among the children of the poor in Lon- 
don, made at the British Lying-in Hospital. " Several women who had 
borne — 

ren Lad lost as many as 



3 child 

4 

5 

6 



. 3 
. 4 
. 5 

. 6 
. 7 
. 8 
. 9 
8 and 10 
10 and 11 
. 11 



"And several mothers of the different numbers had lost them all. 
During another long period, only one woman, having borne as many as 
five children, had reared them all ; and one having had twelve, had 



Medical Statistics, p. 130. 



2 On the Management of Infancy, p. 22. 



INFANCY AND CHILDHOOD. 23 

eight living. But some, having ha,& four, had lost three ; and five had 
lost four ; and six, five; and seven, six; and eight, six and seven; and 
ten, seven and nine; and women having borne eleven and twelve, had 
lost eight, nine, and ten; and fourteen, eight; while many, who had 
borne four, five, and six, one twelve, and another twenty-one, had buried 
them all. In addition to this, may be remarked the sad and rickety 
state of many of the surviving children." 1 

10. I quite agree with the remark of Dr. Combe, that, although it 
be in hospitals and other institutions for children that the most fearful 
results of bad management have occurred, "we must not infer that the 
records of family practice are altogether unstained with cases of a 
similar nature, and that among the wealthier classes, at least, nothing 
more can be done for the preservation of infant health and life. On 
the contrary, we have too good reason to believe that, even among the 
best educated classes, many lives are cut short by mismanagement in 
infancy, which might be saved, if the parents only possessed in time a 
portion of that knowledge and practical sense which dire experience 
sometimes impresses upon them when too late." 2 

11. The facts which have been laid before the reader — and which are 
not a tithe of what might be adduced — are sufficient to show that a 
large proportion of infants are stillborn; that another large proportion 
die in early infancy; that this proportion is vastly increased by bad 
management, and may be diminished by good management ; and that 
there will still remain a large mortality from disease, arising from causes 
over which we have but little control, but which may still be diminished 
by judicious medical treatment. 

Thus the work before us is naturally divided into an inquiry, first, 
into the causes of disease during intra-uterine life, or immediately after 
birth ; secondly, into the management of infants and children ; and 
thirdly, into the diseases which are peculiar to, or very prevalent during 
infancy and childhood. 

It does not, however, form part of my purpose to give more than a 
brief sketch of the first division ; and as the book is written for medi- 
cal practitioners rather than for nurses, I shall content myself with 
laying down the leading principles that ought to guide us in the manage- 
ment of children, instead of minute details ; reserving the main portion 
of the work for a full and careful consideration of the diseases incident 
to this period of life. 

12. Let us first consider the circumstances in which the infant is 
placed during intra-uterine life. During the nine months of gestation, 
the foetus, inclosed in the membranes, is immersed in, and surrounded 
by the liquor amnii, which has the double effect of preserving an equable 
temperature, and diminishing the effect of external shocks, and of the 
movements of the mother, upon it. It is connected with the mother by 
means of the placenta and funis umbilicalis, and, through the medium of 
these structures, that change in the foetal blood is effected which is 
essential for the life, nourishment, and growth of the child. 

1 On the Diseases of Children, tenth edition, p. 85. 

2 On the Management of Infancy, &c, p. 25. 



24 ON THE MANAGEMENT OF 

Apparently, whatever communication there is between the mother 
and child is very indirect, i. e., anatomically speaking, but we have 
pathological evidence of a very direct influence exerted by the parent 
upon her offspring — in those cases, for example, where mental emotion 
in the former has quickly extinguished life in the latter; and those in 
which children have exhibited at birth, traces of disease which must 
have been acquired through the mother. 

13. What are the active organic functions during intra-uterine life ? 
Almost exclusively those connected with nutrition. Aeration of the 
blood in the placenta (which is a vicarious and temporary substitute for 
the lungs) or uterine sinuses — absorption of the contents of the vesicula 
umbilicalis at an early period, and of the liquor amnii by the skin, and 
perhaps by the stomach, at a later — are functions which are evidently 
active. 

We have also evidences of a limited amount of excretion in the meco- 
nium contained in the intestines, and in the urine by which the bladder 
is often filled at birth. The circulating system is, of course, active as 
an agent in the growth and development of the foetus ; the respiratory 
system is quiescent. The nervous system is, in general, so far as we 
can judge, inactive, except as it may be involved in the general 
organic development, although the sudden movements of the child, when 
cold is applied to the abdomen of the mother, show a quick sensibility 
to alterations of temperature. 

14. So far, then, the condition of the foetus in utero is one of quies- 
cence, except as regards the functions of nutrition and development. 
Secluded and protected by exquisite arrangements, in its temporary 
abode, from all external influence and injury, it is at once, at the termi- 
nation of gestation, plunged into the midst of excitement, and exposed 
to influences and impressions which act rudely on organs hitherto un- 
tried. " In one instant it is transferred from unconscious repose, solitude, 
and darkness, to life, and light, and action. From being surrounded 
by a bland fluid of unvarying warmth, it passes at once to the rude con- 
tact of an ever-changing and colder air, and to a harder pressure, even 
from the softest clothing than it ever before sustained. Previously 
nourished by the mother's blood, it must now seek and digest its own 
food, and throw out its own waste. The blood, once purified and re- 
stored through means of the mother's system, must now be oxygenated 
by the child's own lungs. The animal heat once supplied to it by an- 
other source must now be elaborated by the action of its own organs." 1 

The first impression, and a most painful one, is that of cold, and the 
first act is to evince its sufferings by cries and struggles. No doubt, 
benefit is derived from this, it assists in establishing perfect respiration, 
and gives an impetus to the general circulation. 

The distress occasioned at first by cold is augmented by the compara- 
tively rough handling, washing, and dressing, and by the stimulus to 
which each sense is exposed. The eye, hitherto closed in darkness, 
opens to the light, and the ear for the first time is exposed to various 
and confused sounds ; and the brain and nervous system, so far used to 

1 Combe on the Management of Infancy and Childhood, p. 180. 



INFANCY AND CHILDHOOD. 25 

but few and simple impressions, become the centre of varied and com- 
plicated ones from each awakened sense, and these impressions, for the 
most part, painful. 

Moreover, a very remarkable change takes place in the posture and 
muscular movements of the infant. Not that it makes no muscular ex- 
ertions previously, but from the small space in which it was confined, 
these were necessarily limited and uniform; a limb could be moved to 
and fro, but complete extension was impossible. Now the infant lies at 
full length, and under the handling of its nurse stretches forth its limbs, 
and struggles violently in its impotent distress. 

Very shortly after birth the organs of digestion are called upon to 
perform their functions, and although the food be mild and bland, yet 
the process is ordinarily a prodigious step beyond the functions hitherto 
performed by the stomach, if indeed this organ was at all active during 
gestation. 

15. When we consider, therefore, that from a state of quiescence, and 
simple organic nutrition, the infant at birth is roused into a state of 
functional and organic activity, with each sense exposed to vivid im- 
pressions from its own peculiar stimulus, and these concentrated, as it 
were, in successive and powerful impressions upon the nervous system, 
it cannot be a matter of surprise that any individual organ should be 
liable to derangement or disordered action ; much less when we reflect 
upon the sympathetic interdependence of organs and systems, and re- 
member how disorders of the one entail disorders in another, and how 
apt simple or complex disorders of organs are to entail serious disturb- 
ance in the nervous system. Under such circumstances, one would 
anticipate considerable liability to disease during the first month, even 
under the most judicious management. 

16. But a little more detail will be necessary to exhibit fully the 
sources of disease to which the infant is exposed before, at, and imme- 
diately after birth. 

Although the foetus in ute.ro be completely protected from external 
morbid impressions of the ordinary kind, yet we do not find it secure 
from indirect influences which may excite disease during intra-uterine 
life. 

From the maternal blood are derived those changes which render the 
foetal blood suitable for nutrition and growth; if the mother be in per- 
fect health, these changes may be expected to be of a natural and healthy 
character ; but if she be unhealthy, whether temporarily or continuously, 
then a corresponding deterioration of the foetal blood may take place, 
and individual organs or the growth of the child may suffer. 

Again, it seems undeniable, though not to be established by anato- 
mical research, that some kind of nervous communication exists between 
the mother and child before birth ; at least it is certain that vivid im- 
pressions, bodily or mental, upon the former, may be transmitted to the 
latter, and injury or even death be inflicted. 

17. Here, then, are two external sources of disease in the foetus, 
originating in the bodily or mental condition of the mother: mischief 
may arise to her child from neglect of herself, from unavoidable ill 
health, or from excessive mental emotion. This consideration is of such 



26 ON THE MANAGEMENT -OF 

importance, and appeals so directly to the most powerful feelings of 
"womanly nature, that it ought to be sufficient to insure an adequate at- 
tention to health in all likely to become mothers. Common sense and 
a little self-denial will generally secure all that is in her power. The 
diet and regimen generally should be arranged so as to afford her suf- 
ficient nourishment without over-feeding, and only a moderate use of 
beer or wine should be allowed. Exercise is necessary to health, but it 
should be taken moderately, and at proper times, avoiding undue fatigue, 
exposure to inclement weather, and wet feet. And it should not be 
forgotten that rest is as necessary as exercise ; so that excessive fatigue 
from violent or prolonged exercise, and from late hours must be abso- 
lutely avoided. After exertion, the use of the couch or sofa, instead of 
a chair, is a great comfort to the patient. 

Her dress, too, will require care, so as to secure warmth and avoid 
all pressure. She ought to be contented to give up the attempt at a 
fashionable appearance, as she must that of a fashionable shape; and if 
she can be persuaded to abstain from parties and numerous assem- 
blages, and late hours, it will be all the better for her own and her 
child's health. 

The authoress of the Good Nurse very sensibly remarks : " When a 
young woman acts from principles of reason and religion, she will con- 
sider proper care of herself during pregnancy an imperious duty, not 
only on her own account, but from the reflection that the life of another 
is interwoven with her own, whom she is bound by every virtuous feel- 
ing to cherish, and that with the utmost tenderness; being aware that 
improper management of herself during this period may be destructive 
of the being for whose life she is responsible. 

" The most important part of her duty is to guard her mind against 
every innovation of temper or uneasiness. When the heart is graced 
with affection, its engaging influence pervades every feeling, and smooths 
and tranquillizes the mind upon all occasions. I am decidedly of 
opinion that if we suffer every trifling disappointment and cross-occur- 
rence to ruffle and disturb us, it is a certain mode of corroding our 
peace and very materially injuring the health ; which at all times 
should be carefully guarded against, but more especially under these 
circumstances." 1 

"During pregnancy," observes Dr. Combe, "the great aim, for the 
sake of both parent and child, ought to be, to sustain the general health 
in its highest state of efficiency ; and in order to attain this, the mother 
ought to pursue her usual avocations and mode of life, provided these 
be such as are compatible with the laws of health. Regular daily exer- 
cise, cheerful occupation and society, moderate diet, pure air, early 
hours, clothing suitable to the season, and healthy activity of the skin, 
are all more essential than ever, because now the permanent welfare of 
another being is at stake in addition to that of the mother." 2 

18. But besides the indirect sources of disease already mentioned, 
another may be found in the temporary apparatus provided for the 

i The Good Nurse, p. 106. 

2 On the Management of Infancy and Childhood, p. 91. 



INFANCY AND CHILDHOOD. 27 

nutrition of the foetus. The placenta may be regarded as a species of 
gland, consisting of a congeries of vessels, and being very liable to have 
its circulation disturbed. This may be temporary, or it may issue in 
inflammation, which may give rise to alterations of structure in one or 
more of the lobes or lobuli of which it is composed. If it be of a very 
great extent, it must, more or less, interfere with the perfect nourish- 
ment of the foetus, and, notwithstanding all the compensating powers of 
nature, the foetus will not infrequently suffer from disease as the conse- 
quence. 1 The same may be said of any malformation or disease of the 
other portions of the foetal apparatus. 

Moreover, we possess ample evidence to prove that the foetal organs 
may be affected by almost as great a variety of diseases as after birth, 
without our being able to trace them to any of the causes just men- 
tioned ; or, in other words, that without apparent external cause, dis- 
eased action may arise and morbid changes take place in any of the 
foetal structures. As I shall have occasion to allude to some of these 
pathological states hereafter, I shall at present merely refer the reader 
to the work of Dr. Graetzer, Ueber die Krankheiten des Foetus, in 
which the author has with great industry collected examples of eighty- 
two different diseases which have been recorded by those in whose prac- 
tice they occurred. 

19. The process of transition into the world, in the vast majority of 
cases, inflicts no injury at all upon the child, but in some cases of diffi- 
cult labor it does not escape so well. Pressure of the head, if beyond 
a certain amount, may injure the brain or cranium ; arrest of the circu- 
lation, by compression of the navel-string or the vessels of the neck, 
may cause asphyxia, congestion, apoplexy, or effusion of blood into the 
substance, or upon the surface, of the brain or membranes. Impaired 
vitality, or death may be the consequence. 

20. After birth, exposure alone, " taking cold," as it is called, is 
often a cause of immediate disorder, the eyes, eyelids, or Schneiderian 
membrane, becoming inflamed. The unused condition of the lungs, the 
sudden access of air to the delicate bronchial tubes, the increased vas- 
cularity of their lining membrane, and the enormously increased circu- 
lation in the lungs, which have ^superseded the placenta in its function 
of aerating the blood, afford ample grounds for the incursion of disease, 
which will be rendered still more probable if the air be too cold or in 
any way impure. Continued crying, from suffering or discomfort, may 
be considered as violence applied to the air-tubes, and anything which 
quickens or renders irregular the circulation in the lungs, may be said 
to add an additional stimulus to diseased action in so delicate an organ. 
Prolonged decubitus has been recently suggested as the principal cause 
of the mortality in the Foundling Hospital of Paris, from its effect in 
producing inflammation of the lungs, and it seems certain that change 
of position and gentle movements are. as necessary for the health of 
internal organs as for muscular development. 

21. The digestive system is exposed to clanger both from the quality 
and quantity of the food submitted to it. The process of appropriating 

1 Simpson on Diseases of the Placenta. Edinburgh Med. and Surg. Journal. 



23 ON THE MANAGEMENT OP 

even the blandest food increases the vascularity of the mucous mem- 
brane and the entire circulation in the organs engaged ; if the food 
should be unsuited, improper, or in too great quantity, instead of 
nourishment, the result will be injury both to the organs individually 
and to the system generally as a consequence. 

22. Excitement of the brain and nervous system is of a multiplied 
and complex character. Possessing exquisite sensibility, each sensuous 
impression is acutely felt, though transitory, and obliterated probably 
by the one succeeding. This variety or succession of impressions is 
advantageous, for the boundary between excitement and irritation of 
the nervous system is so easily passed, that a deep or prolonged impres- 
sion could scarcely be without injury, as we see when an infant is 
exposed to an excess of light or noise ; but this is even more evident 
when we reflect that impressions from more than one sense are concen- 
trated upon the brain at the same time. The natural or unnatural 
stimulus to any organ is a stimulant to the nervous system of more or 
less power. To give an illustration of what I mean, it is clear that a 
very bright light will stimulate the brain through the organ of sight, 
and singly it might be injurious; but if at the same time the ear com- 
municate a painful impression of a loud noise, and the skin of rough 
handling, the stimulus to the brain is tripled, and the probabilities of 
injury so much increased. 

If, however, the natural action of the organs of sense upon the brain 
may be injurious, how much more so must be their diseased action, and 
that of other organs also ? The relation which the organs of sense, in 
their normal condition, bear to the nervous system, is evident ; not so 
that of the other organs of the body; the close tie which connects these 
latter is principally evidenced in cases of disease. Thus we find that, 
while healthy food is digested with no apparent effect upon the nervous 
system, indigestible food may excite convulsions, &c. 

Many similar examples might be adduced to prove that disordered 
action of different and distant organs is concentrated, as it were, upon 
the nervous system, giving rise to secondary but very important dis- 
eases thereof. 

23. From this cursory sketch we may see that the infant is exposed 
to various causes of disease both before and after birth; that previous 
to its entrance into the world it may receive direct injury from its 
mother; or, indirectly, through the deterioration of her blood; that 
disease in its temporary organs of nutrition or in its envelops may 
inflict damage upon the foetus ; and that none of its organs are exempt 
from diseases which are excited by causes beyond our means of appre- 
ciation. 

Again, the process of transition into the world may leave injurious 
effects upon the organ or structure submitted to pressure, or if the com- 
pression be excessive, it may prove fatal. 

Lastly, supposing the infant to escape with impunity so far, each 
organ and system has to undergo a severe trial at the assumption of its 
natural functions. From the newness of all impressions, and from the 
organs not having acquired the power of adaptation and modification 
which they subsequently possess, the natural food of each, the very pro- 



INFANCY AND CHILDHOOD. . 29 

cess of nutrition and support, may excite disease. That which each 
organ seeks as its pabulum (e.g., light for the eye, food for the stomach, 
&c), may, in its delicate state and unlimited exposure, be highly injuri- 
ous from its quantity or quality. 

The intricate and extensive sympathies of the different systems, 
slightly evident in health, but very marked in disease, are another source 
of mischief. In childhood scarcely any disorder exists alone for any 
length of time, and we shall find hereafter that the secondary diseases 
of childhood are not inferior in importance, and require as careful an 
adaptation of remedies, as the primary ones. 

If we add the evils that result from bad management, the cause of 
the great mortality in infancy will be in a great measure explained, and 
the best reason given for the rules I shall lay down for the management 
of children. 

24. But before commencing this subject, it may not be amiss to notice 
the organic peculiarities of childhood, and to say a few words upon the 
growth and development of the infant. 

Respiration being established, and the lungs distended, the volume of 
the chest is materially increased and continues to enlarge for some time 
in its full proportion. The heart, also, having some work to perform in 
transmitting the blood through the lungs, acquires greater size. The 
pulmonary bloodvessels are largely developed, and are occupied in car- 
rying the blood to the lungs to undergo the process of aeration. The 
foramen ovale, which allowed the blood to pass from the right to the left 
auricle before birth, is gradually closed, and the ductus arteriosus obli- 
terated. During early infancy the circulation is rapid, the pulse being 
from 100 to 120 or 130, and the respiration proportionably quick; as 
the age increases, these both gradually subside. 

The principal peculiarity of the digestive system appears to be the 
balance there is between nutrition and excretion, and the rapidity of 
these functions. Children eat oftener and evacuate more frequently 
than older persons, and upon the due proportion between the two, their 
health in a great measure depends. 

The nervous system is remarkable for its delicacy, the rapidity with 
which its functions are performed, and the quick exhaustion which fol- 
lows. A child will exert himself in a greater ratio than an adult, but 
he requires more sleep. 

The power of generating heat in infancy is much less than in after 
life. The great sources of animal heat are respiration, digestion, and 
the nervous influence. "If, then, free respiration, vigorous digestion of 
nourishing food, and active nervous influence, are the chief sources of 
animal heat, it would be contrary to reason and common sense to expect 
its rapid evolution in infancy, the very period at which these functions 
are most imperfect and come into play for the first time, amidst an act- 
ive revolution in the state of living and habits of the child, which is 
anything but favorable to their exercise. How can respiration be free 
and vigorous when the lungs are still small and their air-cells still im- 
perfectly expanded ? And how can the new-born infant produce heat 
from chyme, which is itself the product of a digestion that has not yet 
taken place ? Again, how can digestion be vigorous where no food has 



80 ON THE MANAGEMENT OF 

ever been swallowed, and when the first aliment derived from the mother's 
breast is so thin and watery as scarcely to admit of digestion at all ? 
And how can sustained nervous energy be healthily supplied when the 
nervous fibres have, for the first time, encountered their objects, and 
whole days are spent in sleep, and when the circulation is driven off" its 
balance by the variety of new functions at once excited into action. To 
the eye of reason it seems impossible to convey these facts without ac- 
knowledging that, to expect the vigorous generation of animal heat in 
such circumstances, would be very much like expecting an oak to grow 
without roots, or afire to burn without air. Notwithstanding this, how- 
ever, it was once, or rather it still is, a matter of popular belief, that in- 
fants have a great power of resisting external -cold, and are even invigo- 
rated by it. But Milne Edwards has now demonstrated that, in accord- 
ance with what might be expected & priori, the power of generating heat 
is at its minimum in all animals immediately after birth, and that it rises 
progressively as their development, strength, and internal activity in- 
crease. In conformity with this rule, it appears that in prematurely 
born children, the heat of the body is several degrees below the natural 
standard, and is very easily depressed still further by external exposure. 
In one instance, of a seven months' child, the thermometer stood at 89° 
Fahr. instead of 98°, or nine degrees below the usual temperature in 
the adult." 1 

The muscular and osseous systems are scarcely completed at birth, or, 
when completed, they have but little of the strength or vigor necessary 
for use, but, as in the case of the internal organs, every day adds to 
their development and power. 

25. Now let us take the case of an infant after the excitement to 
which it is immediately exposed at birth. Under the influence of ex- 
haustion it sleeps long, and each hour of excitement is thus followed by 
rest for the senses and for the nervous system, and during these periods 
of rest, and in consequence of them, nutrition and growth proceed ra- 
pidly. Food, excitement, and sleep, divide the life of infancy, but the 
latter preponderate considerably in health. By degrees the organs of 
life become used to their food and able to employ it beneficially ; the 
organs of sense are accustomed to the stimulus presented to them, and 
cease to feel it so acutely, or (as in the case of the eye) acquire the 
power of limiting its extent ; and the nervous system, still sensitive, 
gives evidence that all sensation is not painful. 

Further, after awhile it is clear that another step in advance has 
been taken, though the proof is slight at first ; the child is conscious of 
something external to himself; he sees, not light merely, but objects ; 
he hears, not sounds simply, but sounds proceeding from something, 
towards which he endeavors to turn. A light object immediately at- 
tracts attention, and if it be moved the infant will endeavor to follow 
it with its eye. If the room be darkened, and a space in the curtains 
admit a ray of light, or if a candle be visible, we may remark that, as 

1 Combe on the Management of Infancy, p. 119. This is an excellent little work, 
■which I would strongly recommend to the notice of all interested in the management of 
children. 



INFANCY AND CHILDHOOD. 31 

the infant of a fortnight old lies on its nurse's lap, it is towards this 
that its eye is steadily directed. 

After this education of the eye to light and luminous objects, and of 
the ear to sounds, and to the sources whence the sounds proceed has 
continued for some time, we may perceive another step in advance — 
the child recognizes certain of them. The mother's voice occasions a 
start and smile of pleasure, and as the eye has acquired not so much 
the power of discriminating between objects as of recognizing one or 
more, the mother's face becomes familiar, and sound and sight together 
elicit from the baby its earliest expression of preference and affection. 

26. But whilst this education of two of the senses for appreciating 
external relationship has been going on, other means of obtaining in- 
formation have come into use. The muscles have acquired strength 
and facility from incessant motion during waking hours, and the touch, 
too sensitive at first, has become so regulated as to be rather a source 
of pleasure. By degrees the child acquires the use of the great organ 
of feeling, the hand, not only in touching objects but in grasping them, 
and the mind has thus opened to it another source of information, 
as to the external world, as extensive and valuable as that afforded by 
the eye. 

By the union of touch with sight, the infant obtains a knowledge of 
forms as distinct from surfaces ; and it is probably to touch chiefly that 
it is indebted for the conception of substance. 

This acquisition of information, concerning external sensible things, 
commences at a very early period : from the beginning the infant grasps 
a finger or any object presented to it ; the next step is to maintain its 
grasp and give a direction to its muscular effort, and this is attained by 
the endeavor to gratify another feeling. That which it seizes it speedily 
endeavors to convey to its mouth, at first with difficulty and uncer- 
tainty, but after many failures the power of direction is acquired, which 
after some time is extended, and the infant can at once put forth its 
hand direct to an object, grasp, retain, and direct it whither it pleases. 
This involves both muscular power and command, and mental or cere- 
bral government. 

27. After this we find another example of muscular action directed 
by the nervous system to a definite object, and modified by the faculty 
or power of imitation. Voice or sounds the child has produced from its 
birth, but it was expressive of two sensations merely, distress and plea- 
sure ; now, however, that the ear has acquired a certain amount of 
knowledge, and the muscles of the mouth and larynx a certain degree 
of power, an attempt is made to produce articulate sounds or words. 
The mother or nurse unconsciously appeals to the faculty of imitation 
with which children are so richly endowed, and after persevering endea- 
vors a simple sound is divided and rendered distinct by the lips, and 
the child's first words, " pa-pa," " mam-ma," are uttered. As a general 
rule, though with many exceptions, labial words are first pronounced, 
then lingual, and lastly guttural. 

Success in uttering one word is at once a reward and an incentive to 
fresh trials, and the distinct pronunciation of one or two is a lesson and 
an example to the child in its further efforts. Its vocabulary increases 



32 MANAGEMENT OF 

■with considerable rapidity, single words are accumulated, complex ones 
are formed, two or more are joined, so as to form an imperfect sen- 
tence, but one sufficiently intelligent for the expression of the child's 
wants or feelings ; and now the mental state is no longer exhibited in 
pantomime, but expressed with a definite consciousness on the part of 
the child ; so as to be understood by those to whom its language is 
familiar. Its mental operations have been extended from the simple 
acquisition of knowledge to the power of communicating its own impres- 
sions to another. The influence of mind upon speech is very well illus- 
trated in the case of idiots, who always learn to speak very imperfectly, 
and often not at all. 

Whilst, then, compound processes have been developing, the entire 
body of the child has increased in size; the muscles of the back and 
lower extremities have become stronger and more active ; the child has 
learned to use his limbs, and to maintain an erect position in the arms 
or when placed upon the floor. If he be put upon his feet and supported, 
he will make clumsy efforts to advance, lifting one leg and then the 
other ; by degrees he discovers how to secure his progress by placing 
one leg before the other. Or he may first learn to creep upon the floor, 
and I think a child acquires a greater command of his limbs than when 
he learns to walk without first creeping. 

Be this as it may, by one means or another he acquires all the mus- 
cular strength, agility, and tact, necessary to walk, and he only needs 
the proper degree of cerebral government, or, as we say, "a steady 
head," to be able to walk alone. But this is not acquired till some time 
after he can walk pretty well with the aid of a finger. At length, how- 
ever, the power of balancing himself and the courage to do so are at- 
tained, so that he can walk alone, and, like every natural acquisition, 
it affords a repayment of pleasure more than adequate to the trouble it 
has cost. 

Having thus sketched the growth of the infant as to its senses, mode 
of acquiring a knowledge of external things, faculty of speech, and 
power of progression, it is not necessary to follow the subject further. 

I shall at once proceed to consider the rules for the management of 
infancy and childhood. 



CHAPTER II. 

MANAGEMENT OP THE INFANT AT BIRTH. 

28. Immediately that respiration is fully established after the birth 
of the child, a ligature is applied around the navel-string, about two 
inches from the navel, and a second a few inches nearer to the mother, 
and the cord divided between them. The infant is then rolled in flan- 
nel and laid upon the bed, or taken to the fire until the nurse is at 
liberty to attend it. Common sense would teach us, as instinct teaches 



INFANT AT BIRTH. 33 

animals, that for some considerable time after birth great care should 
be taken to keep the infant warm, and observation only confirms this 
necessity by showing that the change of locality at birth involves a dif- 
ference of at least twenty degrees. Dr. Edwards' experiments have 
clearly proved the absolute necessity of increased warmth being afforded, 
to the infant ; and it is to be hoped that the foolish and injurious theories 
about hardening infants by exposure, using cold water, &c, will soon, 
by common consent, be exploded. 

29. If the infant be very weak, it may be desirable to allow it to rest 
awhile before washing and dressing; but, in ordinary cases, the child 
may be taken to the fire and be washed and dressed immediately. Let 
the nurse so place herself that the infant may feel the warmth of the 
fire, but without being exposed to a bright light, and in many cases 
simple warm water will be sufficient to cleanse the skin. When it is 
thickly covered with the vernix caseosa, or creamy matter, neither warm 
water alone nor with the addition of soap will entirely remove it. Dr. 
Dewees recommends "that every part of the child should be smeared 
with fine hog's lard before water is applied. This being done, the child 
should then be carefully washed with lukewarm water and fine soap." 1 
Dr. Eberle mentions that fresh butter or the yelk of an egg is equally 
effectual. 2 Both lay great stress upon the necessity of its complete re- 
moval. Now, without going so far in the opposite extreme as the Ger- 
man professor referred to by Dr. Dewees, who advised its being allowed 
to dry and drop off spontaneously, I do think that to prolong the ope- 
ration of washing unduly for this purpose is unnecessarily exposing the 
child to cold and irritation. Let the nurse apply the lard, and after- 
wards, with a fine soft sponge, or flannel and soap and water, remove 
what she can in a reasonable time ; the rest can easily be removed on 
the second washing after a few hours. 

The head and face should first be washed, the eyelids and ears care- 
fully cleansed, and the whole having been dried with a piece of soft 
linen, a flannel cap should be put on until exchanged for a warm 
nightcap when dressing is completed. In this country it is customary 
to apply a little whiskey to the head after drying it, to prevent cold. 
"Whether it has this effect or not I cannot say ; I do not think it ne- 
cessary, but neither do I think it injurious, provided it be kept from the 
eyes. 

Although the first washing of the child may be somewhat slightly 
performed, the second ought not, but the greatest care should be taken 
to cleanse not merely the general surface of the body, but all the folds 
and creases of the skin, e. g. those of the neck, axillae, groins, buttocks, 
&c. ; and, after drying them gently and thoroughly, all the parts where 
friction of one surface against another is possible should be well dusted 
with finely powdered starch or lapis calaminaris, or hair powder, or 
lycopodium, tied up in a little muslin bag. Eberle objects to this, as 
interfering with the regular transpiration of the skin, and as giving rise 
to a troublesome itching and harshness of the cuticle. 3 I cannot say I 

1 Diseases of Children, p. 71. 2 Diseases of Children, p. 18. 

8 Diseases of Children, p. 21. 

3 



31 MANAGEMENT OF THE 

have ever observed this except when the nurse had neglected to wash 
the parts so powdered, and general experience is certainly in favor of 
it. Excoriations are undoubtedly the result of neglecting this precau- 
tion, especially in fat infants. 

30. After the child has thus been washed, dried, and dusted, the first 
step in dressing is to arrange the navel string ; and it is well for the 
medical attendant to have an eye to this himself, first examining the 
cut extremity, to ascertain if there be any escape of blood, and if so, 
applying an additional ligature nearer to the abdomen. This is ren- 
dered necessary in many cases by the escape of the gelatinous fluid 
contained in the sheath of the cord, which renders the first ligature 
useless, and exposes the infant to hemorrhage when reaction takes 
place after washing and dressing. This point being secured, the frag- 
ment of the navel string is to be folded in a small piece of soft linen, 
and turned upwards on the abdomen, where it is to be retained by a 
light flannel binder, applied firmly and evenly, but not too tightly, 
which answers the double purpose of security to the cord and support 
to the navel specially, and to the abdomen and back generally. 1 The 
nurse should be careful not to wet the dressing of the cord when wash- 
ing the child, and it need not be changed more than once or twice, if 
at all, before the separation of the fragment, which takes place sponta- 
neously about the fifth or sixth day. I have known it to separate as 
early as the second day, and, on the other hand, to be retained until 
the fifteenth; but, however long may be the time, no effort should be 
made to detach it, as the risk of fatal hemorrhage would be very great. 

31. The dress of the infant varies in different places, nor is it of 
much consequence, provided we secure warmth and freedom, that the 
materials be soft, that the parts be not too complicated, that too many 
pins be not used, and that undue and irregular compression of any part 
be avoided. Buffon gives a graphic description of vicious dressing in 
France, which may be observed at the present day : " With us in 
France, an infant no sooner leaves the womb of its mother, and has 
hardly enjoyed the liberty of moving and stretching its limbs, than it is 
clapped again into confinement. It is swathed, its head is fixed, its 
legs are stretched out at full length, and its arms placed straight down 
by the side of its body. In this manner it is bound tight with clothes 
and bandages, so that it cannot stir a limb ; indeed, it is fortunate that 
the poor thing is not muffled up so as to be unable to breathe ; or if so 
much precaution be taken as to lay it on its side, in order that the 
fluid excretions voided at the mouth may descend of themselves; for 
the helpless infant is not at liberty to turn its head to facilitate the 
•discharge." 2 

Dr. Dewees and others of high authority, recommend that flannel 
should be used next the skin; from this, however, I must beg to differ; 
it is not necessary in order to secure sufficient warmth, and a little 
muslin or linen chemise is much softer and cleaner than any other inner 
garment; it should be changed every day, and flannel may be used 
outside. Except the chemise, all the garments are made long, for the 

1 Dewees, Diseases of Childreu, p. 81. 2 Histoire Nat., vol. iv. p. 190. 



INFANT AT BIRTH. 35 

sake of warmth, and if the parent possess common sense, she will not 
adopt the cruel fashion of short sleeves. The nurse should be very 
careful to change the napkins the moment they are soiled, as otherwise 
the buttocks will become inflamed and excoriated, and the child exposed 
to great suffering; and when changing them, warm water and a soft 
sporge must be used if necessary. 

The cap should be soft and warm, so as to protect but not compress 
the head. 

When the child is washed and dressed, which should be done in less 
time than we have taken to describe it, it may be placed in bed with 
its mother, or, wrapped in a flannel shawl, be laid in its cradle, in a 
warm part of the room, equally removed from light and draughts. 

32. About this time, however, or shortly after, it is customary to 
give a grain of calomel, a few grains of rhubarb, or a teaspoonful of 
castor oil, for the purpose of clearing away the meconium. This has 
been objected to as unnecessary, on the ground that the first milk of 
the mother possesses purgative qualities. Granted, but then it is not 
available for hours, or it may be days, and certainly the infant seems 
uneasy until the meconium has been evacuated. It is better to take a 
middle course ; to allow a few hours' rest after washing and dressing, 
and then, if the bowels are not spontaneously moved, to give a tea- 
spoonful of castor oil in a little warm water and sugar. I think the oil 
a better medicine than either calomel, rhubarb, or magnesia. 

When the complexion is changing about the third or fourth day, and 
the skin presents an unusually yellow tinge, without being actually 
jaundiced, then a grain of calomel will be found very beneficial. 

33. For some hours the child will not require food ; its first necessity 
is warmth and sleep. After the oil has been swallowed it should be 
placed in bed or in the cradle, and allowed to rest as long as it will. 

On awaking it will generally be found to have passed water, and per- 
haps to have evacuated the bowels, and as it will then feel hungry, it 
will intimate the same in a way not to be mistaken. At this time, say 
three or four hours after birth, the secretion of milk has not generally 
commenced, and therefore the nurse must feed the child. A little milk 
and water nicely sweetened, will be the best food at this period ; it is 
more simple, and less likely to irritate the delicate mucous membrane of 
the stomach, than gruel or prepared barley, &c. 

Dr. Maunsell states, that " Professor Joerg recommends that nothing 
should be given but a few teaspoonfuls of lukewarm water, and we 
happen to know that such is his practice, without any bad results, in the 
lying-in hospital at Leipsic." 1 

But it cannot be too constantly remembered, that the proper food for 
the infant is the mother's milk, and that the earlier we endeavor to 
obtain this the better for both. 2 To the infant it affords the simplest, 

1 On Diseases of Children, p. 34. 

2 Kaulin (De la Conservation des Enfans, vol. ii. p. 177) in 1769, and Deleurye (La 
M6re selon l'Ordre de la Nature, p. 32) in 1772, recommend an early application of the 
child to the breast. The latter advises that it should be suckled as soon as the mother has 
rested and become tranquil. 

The same opinion is held by all the more sensible -writers since. " The child," says 



36 MANAGEMENT OF THE INFANT AT BIRTH. 

most natural, and healthy nutriment, and the mother may be thus saved 
from uterine hemorrhage, 1 mammary congestion, and milk fever, which 
latter are so frequent when nursing is postponed for three or four days. 

The child should be put to the breast, and allowed to make the at- 
tempt to suck, as soon as the mother has recovered from the fatigue of 
labor, say in eight or ten hours : if the secretion have not commenced 
it will not persist, and must be fed, but in most cases it will obtain some 
milk, and by the effort the ducts will be freed, and the secretion quick- 
ened. So long as the supply is inadequate, the deficiency must be sup- 
plied by a little milk and water with sugar, but if the breasts secrete 
any, the child should be applied to them when it is hungry, before we 
have recourse to feeding. 

34. In may cases, after the first child, the mother is able to begin at 
once, and to continue to nurse her infant, without additional aid; but 
in others, especially in primiparae, we sometimes find that no milk is se- 
creted for two or three days. 2 Now in such cases to let the child suck 
frequently would not merely be useless, but positively injurious ; it 
would obtain no nourishment, and the nipple would be irritated, in- 
flamed, and excoriated. 3 The child should be fed, and only once or 
twice a day placed to the breast. 

Dr. Darwall, " should be put to the breast as soon as the mother has recovered from the 
immediate exhaustion of labor. In this way the breast, tender, probably, and easily ex- 
coriated, gradually becomes able to bear the increasing strength of the child. At first 
its suckling is little felt, its efforts being feeble, and scarcely sufficient to draw in any 
nutriment ; gradually the milk is more plentiful, the exertions of the infant more vigorous, 
but at the same time the breast is become more capable of enduring them." — Plain In- 
structions for the Management of Infants, &c, p. 6. 

1 Underwood, Diseases of Children, p. 29. 

2 With women of a nervous temperament, who are excessively anxious to nurse, this very 
anxiety may postpone or suspend the secretion of milk. No doubt every one has met 
with cases of this kind, which are not always easy to manage. I have found a suggestion 
of my friend, the late Dr. Graves, very successful. Order some "milk powder," — a few 
grains of some innocuous or inert substance, e. g., Pulv. Contrayervse, — to be taken three 
times a day, and give the patient assurance that after three or four days the milk will be 
produced. The anxiety thus relieved or postponed will allow nature fair play, and in the 
majority of cases your "powders" will have the credit of success. 

3 Few things occasion greater suffering than cracked or ulcerated nipples, and it is not 
always possible to avoid them. I have found a modification of Professor Osiander's me- 
thod the best means of avoiding them. For a month or six weeks before confinement the 
nipples should be washed night and morning with fine soap and water, and after carefully 
drying them, they should be bathed with equal parts of spirits and water. Dr. Strahl 
recommends a lotion made by digesting six drachms of galls in six ounces of white wine 
for twenty-four hours, to be applied three or four times a day, beginning at the sixth 
month. Any mild astringent will answer the purpose — green tea, decoction of oak bark, 
alum and water, &c. Dr. Dewees prefers the "application of a young but sufficiently 
strong puppy to the breast — this should be immediately after the seventh month of preg- 
nancy." — p. 54 



THE FOOD OF INFANCY AND CHILDHOOD. 37 



CHAPTER III. 

THE FOOD OF INFANCY AND CHILDHOOD. 

35. Having thus described the treatment of the infant immediately 
after birth, we shall next speak of its further management as regards 
food, clothing, air, and exercise, &c. ; but as a considerable change 
takes place in the habits of the child in the course of the second year, 
we shall speak of the care necessary during the first period of life, or 
infancy, and the second, or childhood, separately. 

From what I have stated in the last chapter, the reader will antici- 
pate the first canon I would lay down as regards food, viz : that as a 
general rule the mother's milk, alone or nearly so, is the proper food of 
the first six months of infantile life, and that it is, with a few excep- 
tions, the imperative duty of the mother to supply it. 

To the credit of those who are below or above the influence of 
fashion — the most contemptible idol that ever man first made, and then 
worshipped — i. e., of the great majority — women in these countries 
anticipate the period of nursing with pleasure, as drawing closer the 
tie between themselves and the objects of their tenderest love. They 
who reject the duty may not unlikely lose a portion of the affection, 
for the natural ordinances of the Creator cannot be violated with 
impunity. 

36. All authors are agreed that human milk is not only the best, but 
one might say the only safe food for infants. The evidence adduced 
by Dr. Merriman against dry nursing is perfectly conclusive. He 
says: "It has been part of my duty to endeavor to ascertain the 
amount of mortality among infants from this source, and after much 
careful inquiry and investigation, I am convinced that the attempt to 
bring up children by hand proves fatal in London to at least seven out 
of eight of these miserable sufferers ; and this happens whether the 
child has never taken the breast at all, or, having been suckled for 
three or four weeks only, is then weaned. In the country the mortality 
among dry-nursed children is not quite so great as in London, but it is 
abundantly greater than is generally imagined. The summer is the 
most favorable season for making the attempt : but if parents were fully 
aware of the hazard to which their children are exposed in the endeavor 
thus to bring them up, they would rarely choose to place them under 
the care of the dry nurse." 1 

37. We may conclude, then, that the best nourishment for the child 
is human milk, and that the proper person to furnish it is undoubtedly 
the mother. But then it may be asked whether this rule is universal, 

1 Underwood, Diseases of Children, p. 13. 



38 THE FOOD OF INFANCY AND CHILDHOOD. 

and without exception ? — whether all mothers can and ought to nurse 
their children? The answer is simply that there are exceptions to this 
rule as to every other, depending upon constitution, temperament, or 
physical peculiarities of the mother, or upon the circumstances in which 
she is placed. These exceptions I shall now enumerate. 

I. In some cases malformation of the nipple presents a great diffi- 
culty, or even an insuperable obstacle. It may be so little prominent, 
or so much tucked in, that the infant cannot seize it. A little care in 
drawing out the nipple during the latter months of pregnancy, or the 
application of a strong child, or a puppy, according to Dr. Dewees, or 
a breast pump, immediately after delivery, before the breast fills, will 
sometimes succeed, if the malformation be not extreme, but if this be 
not effected before the breasts are distended, there will be little chance 
of success. I have seen one case, but only one, in which the ducts 
were imperfect or impervious ; for, notwithstanding that the breasts 
were distended with milk, not a drop could be obtained by the infant or 
by an older child, or by the breast pump. The lady has had three 
children, and was equally unable to nurse with all. 

II. I have seen the milk abundant for a time, and then suddenly 
cease entirely, without apparent cause, the mother being in perfect 
health, and free from anxiety. In one case of this kind the lady 
nursed well for three months, menstruation then occurred, and when it 
ceased there w r as not a drop of milk in the breasts. There is nothing 
capable of restoring the secretion in such cases. 

ill. Occasionally, when the nipple is good, and the supply of milk 
pretty fair, it is in a great measure lost during the intervals of suck- 
ling ; there is a sort of incontinence of milk. It is secreted when not 
wanted, and escapes as fast as secreted. If this should happen, as I 
have known it, in a case where one breast is useless in consequence of 
former disease, there will be a very inadequate support for the infant, 
and unless feeding agree very well with it, it will be better to obtain a 
wet nurse at once. 

It is by no means uncommon for one breast to secrete much more 
milk than the other, or even for one breast to be nearly quiescent, with- 
out apparent cause ; but if the other breast secrete plentifully, and 
retain it, this will be no obstacle to the mother's nursing. 

iv. Women of an irritable, nervous temperament are seldom very 
good nurses. They are so much excited by external and even trifling 
circumstances, that the milk is constantly varying both in quantity and 
quality, and the child will suffer in consequence. Their fears are 
aroused by every little change in the child's condition or appearance, 
and they suffer so much distress that they are not unlikely to cause in 
this way the very danger they fear. 

Moreover, in women of this temperament the constitutional disturb- 
ance excited by nursing is too great for their own health or that of the 
child, especially with first children. I have seen a quick pulse, nervous 
tremors, night sweats, languor, and cough, which were alarming the 
patient's friends, disappear in two days on weaning her child. Drs. 
Gooch and Ashwell mention cases of mental disturbance depending on 
nursing, and I could add several more. For their own sake, then, and 



THE FOOD OF INFANCY AND CHILDHOOD. 39 

for their infant's, women of a nervous, excitable character should abstain 
from nursing their first child at all events. 

v. It is quite out of the question for any woman to nurse who is 
laboring under severe organic disease, fever, exhausting discharges, or 
complaints which are hereditary or transmissible, such as phthisis, epi- 
lepsy, scrofula, syphilis, mental disturbance, &c. Nay, even a known 
tendency towards some of these diseases, their occurrence in any mem- 
ber of the family, or a general delicacy of constitution, should give rise 
to very serious consideration on the part of the physician, before he 
permits his patient to run the risk of perpetuating in her offspring such 
formidable disorders. Children of very delicate parents, when nursed 
by healthy countrywomen, are often found to grow up with constitu- 
tions more resembling their nurse than the mother. The chain of 
transmission has been broken. 

VI. Experience will show in many cases, where it would not have 
been anticipated, that the mother is unfit to continue nursing. Some- 
times, without any apparent cause, the -milk evidently disagrees with 
the child — either it vomits it all, or it is griped and purged, and does not 
thrive. In such cases it will be advisable to make a change. When 
menstruation occurs during lactation, the milk is apt to disagree 
temporarily; but if pregnancy takes place, the disturbance may be 
more permanent. In the former case the infant should be given the 
breast less frequently for a few days, but in the latter it should be 
removed altogether. 

vii. The mother may be so circumstanced, that she cannot under- 
take the office of nurse. Imperative (or imperial) duties and occupa- 
tions may require her absence from her baby for so long a time during 
the day as to prohibit her undertaking the office without injury to the 
child. 

Fashionable life makes such heavy demands upon the time, energies, 
and health of its votaries, that it is fortunate for the child when 
mothers, who cannot give up their amusement, do not add to their folly 
by attempting to nurse. 

Viii. Lastly, great mental emotion, such as grief for the loss of 
relatives or dear friends, anxiety and worry from domestic trials or 
great public calamities, have an injurious effect upon the milk, and may 
seriously injure the child, although the mother's health may not appa- 
rently suffer. 

I have met with an instance of two sisters, who continued to nurse 
their infants during a time of severe domestic trial, and although the 
children were both healthy previously, yet, shortly after, one was 
attacked with arachnitis, and the other with an aggravated form of 
scrofula; both died. 

38. These cases, and some others which may possibly occur, form 
exceptions to the rule laid down, that every mother ought to nurse her 
own child. 

I have already stated, that the sooner the infant is put to the breast, 
after the mother has obtained a little rest, the better both for mother 
and child. 

If the milk be deficient in quantity, a little food may be given, but 



40 THE FOOD OF INFANCY AND CHILDHOOD. 

if the natural supply be adequate, or as soon as it becomes so, the child 
should be nourished by the mother alone, if strong enough, for some 
months, both night and day. The frequency with which the child 
should be put to the breast will vary a little according to its appetite, 
but it is desirable that, as far as possible, it should acquire regular 
habits of feeding. Every two or three hours will not be too frequent, 
if no food be given, and it will be well, if the nipples be tender, to 
bathe them with spirits and water each time after suckling, and with 
warm water before the next nursing, in order to prevent cracks or 
excoriations. A recent author has attributed the excoriation to the 
action of the infantile saliva upon the tender skin of the nipple, and 
has recommended washing with water after each application of the 
infant. 

39. After four or five months it will be advisable to feed the child 
regularly once a day, so that, in case of an interruption or diminution 
of the natural supply from any cause, it may not suffer. As the child 
grows older, and its appetite increases, the mother may not have 
sufficient, and the feeding must be increased in quantity and frequency, 
at the same time it ought to have the benefit of all the natural food. 

Of the varieties of food, and modes of administering it, I shall have 
to speak fully by and by ; at present, therefore, I shall merely observe, 
that the food should be given as thin as possible at first. The nurse 
prefers it thick, " because," she says, " it is more satisfying ;" and no 
doubt the child is quiet and heavy afterwards ; but it is because his 
stomach is overloaded, and if it did not reject its load he would be liable 
to serious illness in consequence. 

In conclusion, I would repeat, that, supposing the mother to be in 
good health, and her milk good and abundant, it is to form the staple 
nourishment of the child until within a short time of weaning ; that he 
is to get all she has to give, and that any deficiency, whether from 
diminished secretion or increased appetite, is to be supplied by feeding. 

40. So far I have assumed that the mother is able and willing to 
suckle her child, but this may not be the case, or after a trial she may 
be obliged to give it up. Then the choice lies between a nurse and 
artificial feeding. There can be no hesitation in preferring the former, 
when a good one can be obtained ; but as the well-being of the child, 
and much of the comfort of the parents, are involved, the medical 
attendant should be extremely careful in his 



CHOICE OF A NURSE. 

Of what may be called the domestic qualifications of the nurse, the 
mother, or some one deputed by her, will be the judge ; but the deci- 
sion as to her suitability as a nurse is very properly almost always 
left to the physician or surgeon. At the same time there are one or 
two points, not strictly medical, which are of importance, and should be 
inquired into. For instance, her temper, habits of life, and any pecu- 
liarity of her position, may be serious inconveniences. If she be liable 
to fits of passion and ill-temper, or indulge any vicious propensities, 



THE FOOD OF INFANCY AND CHILDHOOD. 41 

or be exposed to anxiety on account of her husband or children, the 
quantity and quality of milk will be depreciated, and she will not be a 
good nurse. 

Again, it is desirable that she should be naturally fond of children, 
that she may bear patiently and kindly their " tracassei'ies," and of a 
lively disposition, that she may amuse them, and keep them cheerful 
and happy. 

41. There is a general prejudice against taking as a nurse a woman 
after her first confinement ; on the ground, I believe, that she has less 
experience, that there is greater liability to menstruation, and conse- 
quent impregnation whilst nursing, and that the milk is less certain in 
quantity, and apt to cease suddenly, after the first child, than subse- 
quently. 

It is desirable to choose a nurse whose child is about the age of the 
one she is to suckle, or rather younger, if anything. At the same 
time, if the mother have suckled or fed her child for some weeks, or if 
it suffer from diarrhoea, it will be injurious to give it very young milk. 
Dr. Merriman observes : " Some ladies are very anxious to procure 
wet nurses who have not lain in more than a fortnight or three weeks. 
I have seldom found the milk of such nurses answer so well as those 
whose children are eight or ten weeks old. They are not sufficiently 
recovered from the effects of parturition, to undertake the duties gene- 
rally required of a wet nurse." 1 

Both mother and child should have the appearance of firm, good 
health ; the nurse should have a clear, sound skin, without eruption or 
traces of scrofulous disease. Her mouth should be examined, and 
the state of her teeth and tongue ascertained ; if the former be perfect, 
and the latter clean, we may be satisfied that the digestive system is 
healthy. 

The breasts should be of moderate size, both equally good, and firm, 
the bulk evidently formed by the enlarged mammary gland, and not by 
adipose tissue. Large, flabby breasts yield a very inferior supply of 
milk. The nipple should be of moderate size, well formed, and promi- 
nent, and we should observe whether the milk escapes involuntarily, or 
only when demanded by the infant. 2 

Let the nurse squeeze a little milk into a wineglass, in order to 
judge of its quality ; it ought to be thin, clear, of a bluish white color, 
very limpid, very sweet, and, if allowed to stand for a while, covered 
with cream. 

It may also be subjected to chemical and microscopical analysis, if 

1 Underwood, Diseases of Children, p. 71. 

2 " Nurses who have not a good supply of milk will occasionally be found to adopt a 
practice, commonly employed with milch cows when brought to market, and called 
' stocking' by the cattle-dealers ; that is, they allow the milk to accumulate in their 
breasts for several hours before presenting themselves for examination, so as to cause 
the examiner to believe that they are very abundantly provided. Young practitioners 
should be especially on their guard against this deception." — Maunsell and Evanson on 
the Diseases of Children, p. 40, note. 

Dr. Peddie has published a valuable paper on the mammary ducts, in the Edinburgh 
Monthly Journal for Aug. 1848, in which he has shown the value of the microscope for 
showing the poverty or richness of the milk, and also for detecting certain of its patholo- 
gical conditions. I would strongly recommend its careful perusal. 



4"J THE FOOD OP INFANCY AND CHILDHOOD. 

there be any doubt, but ordinarily the characteristics mentioned above 
will be sufficient. 

42. But a still more minute examination must be made to ascertain, 
as far as possible, whether the nurse is suffering from any disease, local 
or constitutional, which she may transmit to the child. " Diseases of 
the skin, as the itch, and some species of tetter, have been so fre- 
quently propagated, as to become familiar to the observation of every- 
body ; and in two instances we had the immediate care of those who 
had received from the nurse the most loathsome and horrible of all 
diseases ; it was communicated not only to the children who were at 
the breast, but also to four older ones." 1 Rosenstein mentions the 
case of a family in Stockholm, in which the father and mother, three 
children, the maid servant, and two clerks, were infected with venereal 
from the nurse. I saw very lately an infant who had been intrusted 
to a nurse for one day, and which was then transferred to another ; 
by the first it was infected, and it again infected the new nurse. 
Many such cases might be adduced, but enough has been stated to 
show, that any carelessness on the part of the medical attendant may 
inflict great injury and distress upon the infant and those connected 
with it. 

Some light will be thrown upon these by a careful examination of 
the nurse's child, which should never be omitted. It ought to be clean, 
free from all eruptions (except red or white gum) about the head, neck, 
buttocks, and groins, and from excoriation at the different folds of the 
skin. Its mouth should be carefully examined and its general condition. 
Its flesh ought to feel firm, and it ought not to vomit more than a por- 
tion of the suck. 

43. If we find the child and mother healthy, and if the milk be good 
and abundant, we may safely recommend the nurse ; but as the change 
is very great for her, care must be taken to counteract or avoid the 
evils which might result from an increase in diet and a diminution of active 
employment. People of the class from which the best nurses are ob- 
tained suffer their share of the hardships of life.. Plain, coarse food 
and probably a scanty supply of it, insufficient clothing, confined and 
uncomfortable dwellings, and hard labor, are the lot of almost all. From 
this state she is taken to what is to her a luxurious dwelling, with warm 
clothing, abundant or it may be extra diet and comparative idleness, 
having little to do but to attend to the infant. It cannot be surprising 
that such a change should in many cases be unfavorable to the health 
of the nurse, and that the milk should occasionally disagree with the 
infant. 

This, however, may be avoided by a little attention to diet and regi- 
men. It is neither necessary nor advisable that a nurse should be 
highly fed ; it will be much better to give her plain, good food, with a 
moderate allowance of malt liquor at dinner, and a bowl of milk or 
gruel at bedtime ; the quantity being not much more at first than 
that to which she has been used. The large allowance of ale or porter 
so commonly given, is not only unnecessary but injurious. Daily exer- 

1 Dewees, Diseases of Children, p. 68. 



THE FOOD OF INFANCY AND CIIILDHOOD. 43 

cise in the open air is essential, a good smart walk will promote diges- 
tion and favor the secretion of milk, if she take care not to overheat 
herself. The bowels should be moved every day, if not spontaneously, 
then by means of medicines. 

It is very desirable that the nurse should be provided with sufficient 
occupation, and care must be taken that personal cleanliness is duly 
attended to. Dr. Bull recommends that " sponging the whole body 
also with cold water, with bay salt in it, every morning, should be 
insisted upon if possible; it preserves cleanliness, and greatly invigo- 
rates the health." 1 

Early habits are desirable ; she should be allowed to retire early to 
bed, and be required to rise early in the morning. 

44. Most of the observations here made upon the regimen and diet 
of the wet nurse apply equally to the mother who undertakes to suckle 
her child. For her, moderate air and good diet, exercise, and occupa- 
tion, with calmness and tranquillity of mind, are equally necessary, but in 
two points she is more likely to fail. Having been accustomed to good 
living, in her anxiety to produce milk she will try to do so by taking 
more food or richer than usual, and by drinking more ale and porter, 
and it is very likely that in so doing she will defeat her own object. 
Dr. Dewees remarks, that "we have often been consulted upon the 
subject of the failure of the milk, when an anxious mother herself, or a 
hireling nurse was concerned, and been informed by them, that they 
had tried everything with a hope of improving it, such as rich victuals, 
porter, ale, beer, milk punch, &c, without success, or it was followed, 
perhaps, by a diminution of it. In such cases we have often succeeded 
in producing a plentiful supply of milk by adopting the opposite plan of 
treatment; for it must be borne in mind, as an important truth, that 
this failure proceeds more frequently from an over than from an under 
quantity of food or of drink. It is a fact well known to all who have 
paid attention to the consequences of arterial excitement, that when it 
amounts to even moderate fare, the milk almost immediately diminishes 
in quantity ; and also, when the action is diminished (provided it had 
not continued too long) by suitable remedies, that the secretion of milk 
again becomes more abundant. Upon this principle we have fre- 
quently prescribed evacuants and abstinence to promote the secretion 
of milk. 2 

The other point in which the mother not unfrequently fails, is in 
calmness and tranquillity of mind. Having a nearer interest in the 
baby, she is more sensitive as to its well-being, and more apt to fret if 
anything be wrong, and being at the same time the mistress of the 
family, she is more exposed to external irritations and annoyances. 
Against the effects of these causes she must firmly strive ; knowing 
that distress of mind will injure her child, she must shun all occasions 
of irritation, and exert all the self-control she possesses. 

I may as well mention here that Dr. MeWilliam has introduced to 
the notice of the profession the leaves of the castor oil plant as a galac- 

' Maternal Management of Children, p. 33. 
2 On the Diseases of Children, p. 9 ( J. 



44 THE FOOD OF INFANCY AND CHILDHOOD. 

tagogue. The leaves of the white bofareira are to be boiled in water, 
and the breasts are to be bathed with this decoction for fifteen or twenty 
minutes. Part of the boiled leaves are then to be spread over the 
breasts, and allowed to remain till dry. This operation of foments and 
poulticing is to be repeated, at short intervals, until the milk is pro- 
duced or increased. Dr. Tyler Smith tried it in several cases, which, I 
think, afford ground for believing that it may be useful. A consider- 
able amount of uterine or ovarian irritation seems to be produced, and 
menstruation or leucorrhoea occurred, so that, perhaps, the application 
may be successful as an emmenagogue as well as a galactagogue. From 
Dr. Rose Cormack's experiments, however, it appears doubtful whether 
the effects result from some special property of the leaves, or from the 
heat and moisture of the poultice. 

Before speaking of artificial food, it will be better, I think, to con- 
clude the subject of nursing by a few words on weaning the infant. 



45. The term of nursing will depend upon various circumstances, 
such as the health of the child or mother, the abundance of milk, &c. &c. 
Some women are not able to suckle more than six or seven months, 
some continue for two or three years. I know a lady who nursed a 
child (now a tall, strong man) until he was able to draw down the 
blinds and bring her a footstool previous to his taking his meal. Astruc 
and others advise nursing for two years ; Mr. Stephens mentions that the 
Mexicans adopt the practice, and the lower orders occasionally practise it 
to avoid pregnancy, but with only a partial success ; for we find from the 
investigations of Dr. Laycock and Mr. Roberton, that a lagre propor- 
tion of females of the lower classes become pregnant while nursing. 
But these cases are exceptions, and I believe it will generally be found 
that nursing prolonged beyond twelve months is unnecessary for the 
child, and positively injurious to the mother in most cases. 1 Taking 
this as one extreme, we may fix the other at nine months, and conclude 
that it is desirable that a child should not be weaned before nine 
months, nor suck after twelve. By this time he will be provided 
generally with a sufficient number of teeth to make use of the proper 
food, and he will have retained the comfort of the breast until he has 
passed through the first trouble of teething. 

46. However, there are circumstances which may require an earlier 
change ; thus, the mother's health may suffer from the excitement of 
nursing at the commencement, or from the constant drain afterwards. 
" If the suckling be continued, the appetite and digestive powers fail ; 
severe pains in the head ensue ; the nervous system becomes greatly 
disturbed ; transient pains, alternating with spasmodic twitches or 
numbness, occur in various parts of the body ; the debility and ema- 
ciation advance rapidly; a multitude of anomalous nervous symptoms 
constantly harass the patient ; a most distressing sense of sinking and 

1 Dr. Ashwell on Prolonged Lactation. 



THE FOOD OF INFANCY AND CHILDHOOD. 45 

emptiness is at times felt at the region of the stomach ; the mind 
becomes disturbed and tormented often with an intense dread of dying, 
or a constant apprehension of some dreadful accident. A last delirium 
and even mania sometimes supervene." 1 

Dr. Gooch, in his valuable work, alludes to mental affections caused 
by nursing. I have seen such myself more than once, and which 
yielded almost instantly after weaning. 

Again, an attack of acute or chronic disease in the mother, or a 
change in the character of the milk, may oblige us to anticipate the 
ordinary age of weaning ; and if the child be not too young, especially 
if he have teeth, and food agree with him, he may be weaned safely; if 
not, it will be necessary to exchange the mother for a nurse. 

47. If it can possibly be avoided, weaning should never take place 
when the infant is unwell or when suffering from teething ; a suitable 
opportunity, when it is free from distress, should be chosen, and it is 
desirable that the season should be favorable. 

As to the weaning itself there is ordinarily little or no difficulty with 
good management. The daily feeding for some time previously will 
have in great measure prepared the child; and if the frequency be in- 
creased it may gradually be made to supersede nursing in the course of 
a week or two, almost without the child missing the breast. Or the 
mother may give the child suck during the night or day only. By this 
means the child will easily be reconciled, and the milk, the supply of 
which is proportioned to the demand, will gradually lessen, and at length 
cease to be secreted. After the child is entirely weaned, if the breasts 
should continue active and uncomfortably full, the milk may easily be 
squeezed out or drawn off by a pipe or bottle, or the breast pump. Some 
purgative medicine will be advisable. 

48. There is occasionally a little trouble, however, with children 
who have not been accustomed to, or have refused, food whilst nursing. 
The child will be very cross and fretful, and lose some nights' rest, but 
if the mother persevere, hunger will conquer at last. Dr. Under- 
wood observes: "I have remarked that infants, who are indisposed to 
feed at all while at the breast, are nevertheless weaned, and feed just 
as well as others, when once wholly taken from it. There is, how- 
ever, in a few children, a little difficulty for the first two or three days 
under any circumstances ; but it is remarkable that the instance at- 
tended with the greatest aversion to common food that I ever wit- 
nessed was an infant who had been allowed a little chicken broth once 
a day for two months before the weaning was entered upon. The 
child was very healthy, slept well, and scarcely cried at all upon its 
being deprived of the breast, and yet would not receive the food it had 
been accustomed to; so that for six or thirty hours it continued averse 
from everything that was offered to it, though it appeared in very 
good humor. After the second day, however, it took a moderate 
breakfast, and in a little time it fed as readily as other weaned 
children." 2 

1 Eberle, Diseases of Children, p. 64, et aeq. 
8 On Diseases of Children p. 75. 



46 



THE FOOD OF INFANCY AND CHILDHOOD. 



ARTIFICIAL FEEDING — SPOON-FEEDING. 

49. The next point for us to consider is, the best mode of rearing 
infants by spoon-feeding, as it is termed. After what has been said, 
and the facts which have been advanced (36), showing the greater mor- 
tality of infants thus nourished, we should never voluntarily choose this 
method; but circumstances may occur which preclude the mother from 
nursing and which prevent the employment of a nurse, whether from 
prejudice, the difficulty of procuring one, &c. &c. No matter from what 
cause, if the decision be made, it is our duty to secure for the child a 
wise administration of proper food. 

50. The earliest food should resemble mother's milk as nearly as 
possible. Mr. Pereira has given the following analysis of different 
kinds of milk : — 



Constituents. 


Cow. 


Ass. 


Woman. 


Goat. 


Ewe. 


Caseine ..... 

Butter 

Sugar of milk .... 
Various salts .... 
Water 


4.48 
3.13 
4.77 
0.60 
87.02 


1.82 
0.11 
6.08 
0.34 
91.65 


1.52 
3.35 
6.50 
0.45 
87.98 


4.02 
3.32 
5.28 
0.58 
86.80 


4.50 
4.20 
5.00 
0.68 

85.82 


Total 


100.00 


100.00 


100.00 


100.00 


100.00 


Solid substances 


12.98 


8.35 


12 02 


13.20 


14.38 



From this analysis we learn that women's and ass's milk are the 
poorest of all, but that they contain most saccharine matter, 1 and in 
choosing our substitute we should either prefer the one which approaches 
nearest to the natural food of the child, or endeavor to modify the dif- 
ferences in that we do take. Thus a large proportion of water and 
sugar should be added to cow's milk, a less amount of each to goat's 
milk, &c. Any of the milks thus modified will generally agree well 
with the child, and may form the staple food for some months; but 
feeding differs practically from nursing in this, that whilst a child will 
thrive upon mother's milk alone for nine months or a year, it seems 
absolutely necessary to change the food occasionally, or the child will 
suffer from derangement of the stomach and bowels. 

Dr. Dewees has laid down some very important rules for feeding 
with milk, a portion of which I shall extract: "1. The milk should 
be pure, i. e., not skimmed, nor previously reduced by water ; and 
should be used as quickly as possible, especially in warm weather, 
after it has been drawn from the cow. 3. The milk should be given 
as soon as possible after its mixture with the water and sugar, lest it 

1 In the 7th vol. of the Dublin Journal, p. 275, Dr. Mone reports an interesting series 
of experiments, from which he deduced the conclusion, that " the casein of human milk forms, 
with most acids, two sets of compounds : the one when a certain quantity of acid is used, 
soluble in water; the other, when a different quantity of acid is used, insoluble in water; 
and that according as each experiment has formed the soluble or insoluble compound, he 
has reported the milk on which he operated to be incapable or capable of evaporation with 
acids," &c. 



THE FOOD OF INFANCY AND CHILDHOOD. 47 

should be disposed to ferment before it is exhibited. 4. It should 
never be mixed but when wanted, and no more should be provided 
than the child will take in a short time, for it is much better to pre- 
pare fresh than to run the risk of its becoming sour before it is used. 
6. In weather that is unfavorable for keeping milk, it should be 
placed in the coolest place that can be commanded, or kept in often- 
changed cold water. 7. Should the slightest tendency to acidity be 
observed in the milk, it should be rejected without hesitation ; nor 
should an attempt be made at its supposed restoration, by using an 
additional quantity of sugar, as this will eventually but increase the 
evil." 2 

51. Various kinds of food are in daily use, many of which are very 
valuable. 

I. The most common is gruel, made from groats or prepared barley, 
strained and sweetened. The great mistake (if it be not in many cases 
wilful) made by nurses, with this as with other kinds of food, is that it 
is given far too thick, so that it overloads and deranges the stomach. 
It should, on the contrary, be made very thin, especially at first, and 
diluted with water or milk. When continued very long without a change, 
it is apt to occasion flatulence, griping, and sometimes diarrhoea ; but 
with an occasional variation, it is one of the best, as it is the most com- 
mon kind of food for infants. 

II. A very nice kind of food may be made from biscuit powder, pre- 
pared rusks, or " tops and bottoms," by steeping them in water boiling, 
and then adding water or milk and sugar in proportion to the age of 
the infant ; the younger it is the less milk should be given. 

III. Pap or panada, made in the usual way, by soaking bread in water 
and adding sugar to it ; but from the quantity of salt, alum, &c, used 
in making the bread, it is apt to disagree with the infant. 

IV. The best food I know, and one which I have found to agree best 
with my own children, is "bread jelly," and it is made thus: a quantity 
of the soft part of a loaf is broken up, and boiling water being poured 
upon it, it is covered and allowed to steep for some time ; the water is 
then strained off completely and fresh water added, and the whole 
placed on the fire and allowed to boil slowly for some time until it 
becomes smooth ; the water is then pressed out and the bread on cool- 
ing forms a thick jelly, a portion of which is to be mixed with milk or 
water and sugar for use as it is wanted. The steeping in hot water and 
the subsequent boiling removes all the noxious matters, used in making the 
bread, and it both agrees very well with the child and the child likes it 
very much. 

V. Arrowroot, made with water alone, or with the addition of milk 
and sugar, is very good food, but as it is somewhat astringent, it is more 
particularly suited to cases where the bowels are relaxed. In such 
cases, also, boiled milk or boiled rice-milk is very beneficial. 

vi. " Two excellent kinds of food for infants," observes Mr. Mar- 
shall Hall, " are sago, thoroughly boiled in very weak beef tea, with 
the addition of a little milk ; and Leman's rusks, called ' tops and bot- 
toms,' soaked in boiled milk. The former of these has rather a ten- 

1 Diseases of Children, p. 91. 



48 THE FOOD OF INFANCY AND CHILDHOOD. 

dency to confine the bowels, and the latter to open them ; they may 
be mixed together in such proportions as effectually to regulate the 
bowels." 1 

VII. In some cases of illness, to be hereafter noticed, rennet whey or 
white wine whey are useful temporary additions or substitutes for the 
ordinary food. An irritable stomach will sometimes retain whey when 
it will reject milk, and wine whey is perhaps the best form of giving 
wine in the collapse from diarrhcea. 

Vlii. I am indebted to a writer in the Med.-Chir. Mevieiv for the 
knowledge of another species of food, viz : carrot-pap, which has been 
strongly recommended to the profession by Dr. Gumprecht, of Ham- 
burgh. It is used in Wallachia and Turkey ; and at the request of Dr. 
Gumprecht, it has been tried, and is highly commended by Miiller, of 
Hamburgh, Manthner, of Vienna, and Miitchmeyer, of Luneburg. The 
reviewer states that " Wakenroder gives the following analysis of the 
expressed and inspissated juice of the carrot : — 

Oil, fatty, \ nf) Sugar, ) 

Oil, ethereal, / J,uu ' Malic acid, I 93. 

Albumen, vegetable, 4.35. Starch, J 

Karrotin, 0.34. Lime. 

Alumina. 

Oxide of iron. 

" But as the scraped root of the carrot contains other matters than 
the above, especially a large quantity of ligneous substance which 
cannot be digested : and which will often remain two or three days in 
the intestinal canal before being discharged, and being highly detri- 
mental to the mucous membrane of children, it becomes important to 
separate that which will be useful from that which will not. Gumprecht 
advises an ounce of finely scraped full grown carrot to be mixed with two 
cupfuls of cold soft water, and allowed to stand for twelve hours, being 
frequently stirred during this period. The fluid portion is then to be 
strained off, what remains being pressed to yield some more. The 
fluid is then to be mixed with the proper quantity of biscuit powder 
or bruised crust of bread or arrowroot, &c, and the pap placed over a 
slow fire until it begins to bubble. Care must be taken that the heat- 
ing be not pushed so far as to cause boiling, or the albumen will co- 
agulate. After its removal from the fire, it is to be sweetened with a 
due amount of white sugar. Dr. Gumprecht states that by mixing the 
carrot juice with biscuit, crust of bread or arrowroot and sugar, we 
obtain all the farinaceous and nutritious elements required, viz: albumen 
and gluten, starch, sugar, fat, and the phosphates of lime and magnesia. 
This food is more particularly adapted for children who have been 
suckled and are being weaned. For those who are brought up by hand 
the following preparation is deemed more advisable : an ounce of very 
finely scraped yellow carrot, and two drachms of biscuit powder are 
to be mixed with two cupfuls of cold soft water. This must stand in 
a covered vessel, in a cool place for twelve hours, to be frequently stirred 
during that time. It is then to be drawn off or strained through a 

1 Underwood on Diseases of Children, p. 64. 



THE FOOD OF INFANCY AND CHILDHOOD. 49 

fine linen cloth. Some sugar-candy and a pinch of salt are to be 
added to the fluid, which may then be administered by means of a 
sucking bottle, care being taken that the food is at the proper tem- 
perature." 

52. Scarcely less important than the kind of food is the quantity 
and the mode in which it is given. Many of the minor disorders of 
children arise from over-feeding, and much discomfort may be occa- 
sioned by the mode of administering it. The child should not be fed 
too often ; every two, three, or four hours, according to circumstances, 
will be often enough, and about a teacupful may be taken at a time, 
but the nurse must be guided in great measure by the habits of the 
infant and its facility of digestion. It will let her know very clearly 
when it is hungry, and it is quite as easy to discover when it has had 
enough. " Much, after all, must be left to the discretion of the nurse, 
but when the infant withdraws its mouth from the bottle, and shows 
little disposition to resume its work after being once solicited by the 
nurse, it will be a good general rule to conclude that it has taken as 
much as its constitution demands or its appetite inclines to, and no 
means should after this be adopted to force it against its desires." 1 

53. There are three modes of administering food to the infant ; by 
the spoon, by the sucking-bottle, or out of a small cup. The first is the 
most common, and answers very well, especially when the food is thick- 
ened as the child grows older, The nurse should place the infant in a 
reclining posture with its head a little raised, and the food should be 
poured slowly into its mouth. If it be poured too rapidly, it may be 
drawn into the opening of the larynx, and the child be in danger of 
choking. 

The best imitation of the natural process is the use of the bottle, as 
the child, obtaining its food by suction, can regulate at will the rate of 
supply, but it is only practicable whilst the food is thin. The only 
care, beyond cleanliness, required, concerns the nipple ; it may be 
formed of chamois leather, in shape and size like the little finger of a 
glove, with a perforation in the end, and it should be changed every time 
it is used ; or a prepared calf's teat may be tried, and this I think bet- 
ter, as it has more firmness, and does not collapse and close from the 
pressure of the infant's mouth, which the chamois leather is apt to do 
unless prevented by the insertion of a small piece of sponge. After 
each feeding the teat should be removed, rinsed, and put into spirits of 
wine and water until again wanted, and the bottle should be washed 
carefully with hot water. It is of consequence that the nipple (whether 
a teat or of leather) should be so long as to prevent the gums of the 
child coming in contact with the bottle neck ; the infant, it must be 
remembered, does not suck with the front of its mouth, but mainly with 
the back part. 

As a substitute for chamois leather or a calf's teat, M. Dardo, of 
Paris, has invented a nipple of thin elastic cork ; and some one else, 
whose name I do not know, one of ivory, from which the earthy mat- 
ter has been removed, and which is flexible and elastic. I have tried 

1 Underwood, Diseases of Children, p, 59. 



50 THE FOOD OE INFANCY AND CHILDHOOD. 

them both, but have not found them so satisfactory as the calf's teat ; 
they appear to me far too short. 

In some cases the child may be fed from a small cup, with its edge 
gently inclined to the mouth ; the infant will partly suck, partly drink 
its food. All children will not do this, but I have seen it adopted even 
from the birth, and it appeared a very good method ; the infant took its 
food quietly, and without the fretting which frequently accompanies 
spoon-feeding, and without the risk of a sour nipple from the careless- 
ness of the nurse. It is very necessary, however, to be careful that the 
food is not poured too rapidly into the mouth. 

54. Either of these methods will answer very well ; it is of more 
importance to impress upon the nurse that the infant is not to be fed 
too often, nor too largely at once (though this error will generally be 
remedied by the stomach rejecting the surplus), nor to have the food 
too thick whilst young. The food must be gradually increased in sub- 
stance as the child advances in age, and then the sucking-bottle must 
be laid aside. If possible, at any rate in the daytime, the food should 
be fresh made each time, and the vessels used carefully washed after- 
wards. In order that these matters be properly attended to, it is 
absolutely necessary that the mother should keep a vigilant super- 
vision over the nurse and nursery. Common sense and the tact 
which is acquired by experience will very soon afford her sufficient 
guidance. 

As the infant grows older, the diet will admit of extension and re- 
quire a change. After the sixth or eighth month, although farinaceous 
food will constitute the bulk of the nourishment, we may allow chicken 
broth or beef-tea occasionally for dinner, or an egg, by way of variety. 
Until the child is prepared with teeth to masticate solid food, we may 
fairly conclude that such is not its natural food, and whatever is un- 
natural is certainly mischievous with children. Dr. John Clarke wisely 
observes : " If the principles already laid down be true, it cannot be 
reasonably maintained, that a child's mouth without teeth and that of 
an adult furnished with the teeth of graminivorous and carnivorous ani- 
mals are designed by the Creator for the same sort of food. If the 
mastication of solid food, whether animal or vegetable, and a due ad- 
mixture of saliva, be necessary for digestion, then solid food cannot be 
proper where there is no power of mastication." A crust of bread, 
rather tough than crisp, for the child to suck, is of great use not only 
in amusing it but in preparing the gums for the exit of the teeth ; it is 
far better than rings and corals, and such like. 

55. Bread and milk early in the morning, or, if the child be old 
enough, a little bread and butter and a drink of milk, will be necessary 
to satisfy the first demands of the appetite ; afterwards, at a convenient 
time, the breakfast may consist either of bread and milk or of bread 
and butter, with milk and warm water and sugar. 

Dinner, which with all children should be early, may consist of 
chicken, mutton, or beef broth, every day, or alternately with farina- 
ceous food, as may seem best. If there be much irritation with the 
teeth, the broth had better be suspended. When the child has teeth 
to masticate it, a little solid food may be given, such as chicken or mut- 



THE FOOD OF INFANCY AND CHILDHOOD. 51 

ton chop, alternating with a dinner of egg and bread, potatoes and milk, 
stirabout and milk, simple puddings, &c. The only drink allowable is 
water, or milk and water. 

The supper should be taken about six or seven o'clock, and may con- 
sist of the same food as the breakfast ; and very soon afterwards the 
child should be put to bed. 

56. Although it is well to make regularity as to meals the rule 
from the earliest age, yet it is a rule which admits of many exceptions. 
If the child complain of hunger between meals, he will be glad of a 
piece of bread or a biscuit, and to such deviations there can be no rea- 
sonable objection ; but if the pretended hunger is only for " nice things," 
we may safely refuse. No doubt, simplicity of diet and regularity of 
living are essential to the well-being of children, but yet it is quite pos- 
sible for parents to be too particular and restrictive. I am satisfied 
that a foundation is often laid for epicurism and gluttony in after life 
by the habit of allowing children to see dainties on table of which they 
are not permitted to partake. They naturally value unduly that which 
they see others enjoy, and the more that it is forbidden to them. I 
confess, for my own part, that I do not think a moderate allowance of 
fruit, pastry, or sweets, to a child above two years old, will do it any 
harm ; and I know that such an indulgence prevents them seeking to 
gratify their appetite in an illicit manner. Except on extraordinary 
occasions, it is much better to have nothing brought to table of which 
the children who dine there may not take their share. A little self- 
denial, if it be such, is surely better than the risk of physical or moral 
injury to one's child. 

On the other hand, the practice of giving a young child a taste of 
everything it may fancy — cakes and sweetmeats at all hours, and 
in improper quantities — is a monstrous invasion of nature, which will 
inevitably entail its own punishment in delicacy, ill health, and suffer- 
ing. 

After the third or fourth year the diet of the child gradually ap- 
proximates to that of the adult ; he takes a mixture of animal and 
vegetable food in such proportions and quantities as are suitable to his 
age, constitution, and appetite : and the intervals between meals 
lengthen. There is one article of diet which, under ordinary circum- 
stances, should be prohibited to children under fifteen or sixteen 
years of age. I mean wine or malt liquor. Neither are at all neces- 
sary, as their digestion requires no stimulus, and reparation is effected 
perfectly by food and rest. To accustom children to them is, to say 
the least, a very bad habit, and it may have very injurious conse- 
quences. 



52 CLEANLINESS. 



CHAPTER IV. 

CLEANLINESS. — DRESS. 

57. It can scarcely be necessary to impress upon my professional 
readers the necessity of cleanliness and thorough ablution, but it is very 
desirable to impress upon mothers the necessity of their seeing that 
this is observed. Not merely does careful washing cleanse the skin 
from impurities, and prevent the irritation which might arise, but it is 
in itself of the greatest value in promoting health. " I consider bath- 
ing," remarks Struv£, "as the grand arcanum of supporting health, 
on which account, during infancy, it ought to be regarded as one of 
those sacred maternal duties, the performance of which should on no 
account be neglected for a single day." 

I have already spoken of washing the infant at birth in warm water, 
and this practice must. be continued daily. Dr. Armstrong and others 
advise the immediate or speedy use of cold water, but in my opinion 
this is a practice utterly indefensible. It causes a great shock and 
much distress to the child ; the circulation is disturbed, and may not 
easily regain its equilibrium ; and there is very great chance of cold. 
Dr. Merriman remarks : " So many instances have occurred within my 
knowledge, of cold bathing, improperly and injudiciously adopted, 
having been productive of serious ill effects, that I should ill perform 
the duty of an editor did I not caution my unprofessional readers to be 
extremely circumspect before they adopt the use of so powerful an agent 
as the cold bath, not only as regards infants, but children further ad- 
vanced in life.'' 1 

58. Each morning the infant should be well washed all over with a 
soft sponge or flannel, and warm water, and in the evening at least 
partially so, before putting it to sleep, after which it should be care- 
fully dried with a soft towel. Particular care must be bestowed upon 
those parts which are liable to friction, as the folds of the groin and 
buttocks, the armpits, the creases of the neck, &c. &c. ; after drying 
them well, they are to be powdered with starch or lapis calaminaris or 
lycopodium. Very little soap will be necessary, and it should not be 
applied to the face at all, because of the risk of its getting into the 
eyes. Great gentleness is necessary in both washing and drying, as 
the skin is extremely tender, and easily irritated. Properly em- 
ployed, friction along the back and limbs is both pleasant and bene- 
ficial. 

In addition to these regular and stated washings, the nates should 
be washed and powdered after each movement of the bowels, in order 

1 Underwood on Diseases of Children, p. 27. 



CLEANLINESS. 53 

to escape excoriation. Moreover, the nurse should watch the infant 
carefully, and change the napkin as soon as it is wet, or after the 
bowels have been moved ; and as the child grows older it may be 
taught to intimate its necessities to the nurse. Allowing the child 
to remain with a wet napkin about it, is to expose it to cold, excoria- 
tion, and distress, to escape a little trouble. " But it should be well 
understood, when we speak of keeping the child clean, that we do not 
consider the repeated reapplication of the same diaper, because it has 
been hung in the air, or before the fire, and dried, as coming within 
our direction. There can be but two reasons for this filthy practice, 
— laziness and poverty. The first should never be considered as a 
valid reason for employing the same diaper several times, nor will 
it, perhaps, ever be urged as one in direct terms ; but it is unques- 
tionably the only one that influences upon this subject, when the second 
does not obtain to render this, even in appearance, excusable. If the 
second reason exist, and the child has not a sufficient change, it were 
much better that it be without a diaper from time to time, than have 
those returned to it, stiffened with salts, and reeking with offensive 
odor." 1 

I would wish to add a word with regard to the powder, lycopodium, 
which I have recommended, and which I have found most useful. Its 
peculiar quality is that, when dusted over a surface, water runs off from it 
without wetting the surface, so that, for some time at least, perfect dry- 
ness is preserved. For children with delicate skin, liable to excoriation, 
nothing can be better, and I have repeatedly seen severe excoriation 
disappear in a few days under its use. 

59. For the first few days, care must be taken not to disturb the 
remains of the navel-string during washing. After the washing is over, 
the rag which envelops it may be changed if necessary, but no effort 
should be made to hasten its detachment, as the consequences may pro- 
bably be unmanageable, and even fatal. It will fall naturally about the 
fifth or sixth day, and then a little scorched rag, or spermaceti spread on 
linen, may be applied. If the navel be red and swollen, a little bread 
poultice may be applied. 

60. When the child is three months old, it will be able to bear cold 
water in washing, if it be healthy, and will be greatly refreshed by it. 
In order to obtain the greatest benefit from it, the washing should be 
concluded quickly, and followed by rapid and gentle friction with a 
warm towel. Or, instead of deliberate washing with a sponge, a cold 
bath may be given every morning, provided that it be not winter, that 
a proper degree of reaction takes place immediately after, and that the 
child is not frightened. I know of no good to compensate for the con- 
vulsive screaming and extreme distress which some children exhibit on 
being put into a bath. Dr. Marshall Hall observes : " The bath should 
indeed never be used so as to leave an impression of coldness, or actual 
loss of warmth, or lividity of any part of the surface. And when we 
consider how readily infants lose their temperature, and how slowly 
they regain it, we shall view the cold bath as one of those measures 

1 Dewees, Diseases of Children, p. 88. 



54 CLEANLINESS. 

requiring great precaution in infancy. The best kind of bath is a 
shower bath of great simplicity. It consists of a tin vessel in the form 
of a large bottle, pierced at the bottom like a cullender, and termi- 
nating at the upper part in a narrow tube; when put into water it be- 
comes filled with this fluid, which is retained by placing the finger upon 
the tube ; on removing the finger the water flows out gradually. The 
quantity and temperature of the water must be proportionate to the age 
and powers of the child, the weather, and the season. It should be 
warm or tepid for infants at first ; afterwards it may be used a little 
cooler. Its tonic effect may be augmented by the addition of bay salt, 
and by much active rubbing. The first few baths may be quite warm, 
and make a sort of commencement, until the infant is familiar with the 
little shower. It may gradually be made a remedy." 1 

61. As the child advances in age, some modification of the general 
ablution becomes necessary, but great care should be taken to insure 
sufficient and frequent washing, even after it has become able to wash 
itself. A large, shallow tub, in which a child can either sit or kneel, 
is an admirable appendage to a nursery. It is rather an amusement 
to the child, and insures a thorough washing, and may be continued 
long after he is able to wash and dress himself. In addition to gene- 
ral ablution at this period, a little extra attention must be bestowed 
upon the hands, face, ears, hair, &c. ; and it is of great consequence, 
in doing so, to inculcate upon the child itself habits of cleanliness, so 
that it shall not be a task to be washed and clean, but a pleasure. It 
may be made a sine qud non that the child shall not appear in the 
family, unless with a proper attention to its person; and that which 
at first is irksome soon becomes associated with the pleasure of staying 
with its parents. 

Careful attention should be paid to the state of the hair and scalp. 
At first it is of course washed all over every day, but after the child is 
a year old, once a week or fortnight will be sufficient, if it be well brushed 
night and morning. Soap will be necessary in washing, or the yelk of 
an egg, which is much better, and leaves the hair beautifully soft and 
clean. 

A good deal of trouble is sometimes occasioned by the scurf which 
accumulates on the top of an infant's head, and the efforts made to 
remove it by means of a small comb only make it worse, from the irri- 
tation it causes: the best means I know is rubbing a little pomatum 
gently over it at night, and washing it off with mild soap and water or 
oatmeal and water in the morning. 

Boys' hair will of course be kept short, and perhaps little girls' hair 
would be none the worse for being so ; but this is a point which every 
mother will decide for herself, independent of medical advice; and, pro- 
vided that the increase of care as to cleanliness (washing and brushing, 
&c.) keep pace with the increase of its length, I should not be inclined 
to interfere. 

1 Underwood, Diseases of Children, p. 33. 



55 



62. In connection with what has been said of cleanliness, it may be 
observed, that the inner and outer garments of an infant should be 
changed every day at least, and that the oftener they are changed with 
older children the better. It would be better for the health and comfort 
of the child if the money that is expended upon fine clothes were em- 
ployed in augmenting the number of its under garments, so as to facilitate 
repeated changes. 

During infancy, the principal object of dress is to protect the infant 
from cold, yet we constantly see this end overlooked for the sake of 
fashion or preconceived opinions. Parents are but slightly aware of 
the suffering and injury which may result. Dr. Edwards, in his 
admirable work, On the Influence of Physical Agents upon Life, 
remarks, that the mortality from cold "is not confined to children 
whom the misery of their parents cannot guard from the rigor of 
the weather, but it operates, to a great extent, without being either 
perceived or suspected, in families enjoying affluence, and in which 
it is believed that the necessary precautions are taken ; because, cold 
being relative, it is difficult from our own feelings to judge of its ef- 
fects on others, and because it does not always manifest itself by 
determinate and uniform sensations. They do not feel the cold, but 
they have an uneasiness or an indisposition which arises from it ; their 
constitution becomes deteriorated by passing through the alternations 
of health and disease ; and they sink under the action of an unknown 
cause. It is the more likely to be unknown because the injurious 
effects of cold do not always manifest themselves during, or im- 
mediately after, its application: the changes are at first insensible; 
they increase by the repetition of the impression, or by its long 
duration, and the constitution is altered without the effort being sus- 
pected." 

63. Admitting the truth of this statement, we may lay down the 
essential qualifications of an infant's dress to be warmth, simplicity, 
and ease. The instinct of animals provides the former for their 
young, and both reason and observation concur in its greater neces- 
sity for the infant. If the dress be complex, it will be the source of 
great inconvenience to the mother and nurse, and render dressing and 
undressing a period of torment to the child; and if, in addition, part 
of it be tight, or undue pressure be made by it, more serious injury 
may be inflicted. I have already given the description of the swath- 
ing of infants in France, according to Buffon, of which the great ex- 
cellence seems to be so to fix and restrain the child that it can neither 
move hand nor foot, nor turn its head. At first one is inclined to 
disbelieve this, or to fancy it a story of ancient times, but I remem- 
ber within twenty years seeing a child thus fastened and bound in 
Paris. That French children so treated grow up into healthy and 
graceful men and women, is no more an argument in its favor than the 
custom of squeezing the heads of Carib children, which does not appa- 
rently enfeeble their brain in after life. 



56 DRESS. 

The question is, not how far we may interfere with, or trespass upon 
nature, but how we can best aid, or at least, not impede her efforts. 
We may do either, but we are accountable to our children and to society 
for the use we make of our power. 

64. It is obvious that the materials of dress ought to vary according 
to the climate and the season of the year, but yet the difference should 
not be so great as in the dress of adults. A considerable difference 
should be made between its night and day dress. 

A broad binder of fine, soft flannel is first swathed firmly, but not 
tightly, around the child's body, and then comes a little shirt of lawn 
or French cambric. Condie 1 and others recommend that a flannel dress 
should be always next to the skin, but this appears unnecessary, at 
least in this country ; it is certainly more apt to irritate the delicate 
skin of an infant, and unless it be changed every day, as the inner gar- 
ment of an infant ought always to be, it is much less cleanly. After 
the shirt will come long flannel petticoats and other articles of dress, 
of divers fashion, according to the customs of the country, and lastly, 
the frock or robe. All these should be long, easy, and warm, so as to 
protect the infant from cold, and yet leave it as much freedom of move- 
ment as is necessary. The sleeves of the frock should also be long. 
As far as possible the dress should be fastened with strings instead of 
pins ; and when the latter are indispensable, large pins are better than 
small ones, as being much less liable to fall out or to prick the child. 
Some authors have recommended that the infant should not wear a cap, 
and some time ago this practice became for a short time the fashion ; 
experience, however, has proved the folly of this attempt at braving 
natural laws to gratify a theoretical prejudice. In this and similar 
ways, I dare say, a race may be hardened, but it is by cutting off the 
weaker members. 

The cap should be made of warm, soft material, fitting nicely, so as 
not to press upon the head, and in tying it care must be taken that the 
string neither chafes the skin nor impedes respiration. As the infant 
grows older the material may be higher, until at six or eight months, if 
the weather be mild, it may be laid aside altogether. 

"As a general rule, the clothes worn at night should be both lighter 
and looser than the day clothes. The additional warmth produced by 
the bed and its coverings renders unnecessary the same amount of gar- 
ments as are required during the day, and would be liable, were no 
change made, to overheat the body, or to exhaust it by causing profuse 
perspiration ; while the least restraint or compression of the limbs, 
chest, or abdomen, renders the sleep disturbed, and, by its impeding 
the free action of the heart and lungs, is liable to produce various 
uneasy sensations or even partial or general spasms. Every article of 
dress worn during the day should be changed on retiring to bed ; this 
is demanded for the promotion of the comfort as well as the health of 
children ; it allows the different portions of the clothing to be aired at 
short intervals, and prevents any injury that might result from the 
gaseous and vaporous exhalations given off by the skin, and imbibed to 

1 Diseases of Children, p. 43, 4th edit. 



DRESS. 57 

a greater or less extent by the clothes, being retained too long in con- 
tact with it." 1 

65. Dr. Dewees, with his usual good sense, recommends " every 
mother with her first child to try her skill daily at washing and dress- 
ing her infant, a week or ten days before her nurse leaves her, that she 
may become familiar with the routine, and gain a little experience in 
the method. Indeed, this cannot be too seriously recommended ; the 
mere handling of the child requires, to do it in the best manner, some 
experience : a mother may learn much as respects this from a handy, 
experienced nurse, and will be amply repaid for looking on during the 
operation." 2 

I would add to this, and especially during the first year, that the 
mother ought repeatedly either to wash her babe herself or to be pre- 
sent the whole time ; this will insure cleanliness, and be a check upon 
the carelessness and slovenly habits of the nurse, and it applies with 
equal force to the process of dressing as of washing. 

66. As the child grows older its dress will undergo several changes. 
At five or six months, if the season be suitable, its clothes may be short- 
ened ; and at the end of the year they may be still further reduced, so 
as to allow of greater freedom of motion. 

After this the dress remains pretty stationary for a time, and then 
assumes the character proper to little boys and girls. The same prin- 
ciples should regulate it throughout — warmth in winter, lightness in 
summer, simplicity and freedom. The entire person should be well 
covered ; the child should be early taught to dress himself wholly or 
in part ; and there must be no restraint or undue pressure by strings, 
or straps, or waistbands. Any attempt to reduce the rounded form of 
a young boy or girl to what fashion has pronounced to be a good shape 
will be exceedingly mischievous to the framework of the body and to 
the organs it contains ; and, instead of a graceful, free-moving child, 
we shall produce an abortive imitation of a man or woman, lacking the 
grace of one and the ease of the other. 

I have already (64) objected to the use of flannel next to the skin in 
infants, but what I then said does not apply to older children. In 
so variable a climate as this, a slight waistcoat of thin, fine flannel, put 
on in November and left off in May, I have found of the utmost service 
in protecting from colds ; it should, however, only be worn during the 
day. 

67. The same principles ought to be the guide of every sensible 
mother as to the dress of her daughter until the bodily development be 
complete. Scrupulous cleanliness, thorough ablution, frequent changes 
of comfortable clothing, no undue exposure of neck, arms, or legs, and 
an entire avoidance of unequal or undue pressure by corsets, shoulder- 
straps, tight shoes, &c. " The only way we can assist in forming a 
really fine figure is to remove all restraint, and secure, as far as possible, 
so free an action to the muscles as will lead to their perfect develop- 
ment." 3 

1 Condie on Diseases of Children, p. 43, 4th edit. 2 Diseases of Children,, p. 97. 

3 Underwood on Diseases of Children, p. 38. 



58 AIR AND EXERCISE. 



CHAPTER V. 

AIR AND EXERCISE. — SLEEP. — MEDICINE. 

68. Pure fresh air, of a proper temperature, is essential to the health 
of the infant ; but for some time this must be obtained without leaving 
the house. For some days the baby should be kept in its mother's 
bed-chamber, and that should be well ventilated; the second or third 
week it may be taken into the nursery during the day, and subsequently 
to other warm, ventilated rooms in the house ; this will afford sufficient 
change of air. 

The period at which it may be taken out of doors will depend partly 
upon the weather and partly upon the constitution of the child. If 
the infant be strong, and the season fine and mild, it may be carried 
out, well wrapped up, and shielded by the nurse's shawl or cloak, soon 
after the completion of the first month; if the weather be severe, this 
must be postponed until it becomes more favorable. But if the infant 
be delicate, we must be more cautious. Sir James Clarke, in his valuable 
work on Consumption, remarks : "A delicate infant, born late in the 
autumn, will not generally derive advantage from being carried into the 
open air in this climate until the succeeding spring; if the rooms in 
which he is kept are large, often changed, and well ventilated, he will 
not suffer from the confinement, while he will probably escape catarrhal 
affections, which are so often the consequence of the injudicious exposure 
of infants to a cold and severe atmosphere." 

Whilst the child is out, the nurse should constantly walk about; 
most of the colds caught by infants arise from her loitering about, 
sitting down, or standing to gossip with her friends. Nothing so 
tranquillizes an infant as a walk in the open air ; it generally sleeps 
nearly the whole time, and few things so materially promote its health 
and strength. 

69. But although I have spoken thus favorably of fresh air, let me 
not be supposed for a moment to sanction the indiscriminate exposure 
of even healthy children for the purpose of hardening the constitution. 
Nothing can be more senseless than such a delusion, except the argu- 
ments brought in favor of it. The infants of uncivilized nations are 
exposed from birth, and survive. But we are not told how many die; 
and, moreover, we are not savages, and our climate is severe. The 
children of the poor are hardy little fellows. Yes, those that survive; 
but we know that a large proportion are destroyed by this very exposure. 
There are no finer men than the Highlanders of Scotland, and yet their 
children are exposed at an early age to all weathers. But many die, 
and it has been truly remarked that of large families it is rare to find 
more than two sons reared to manhood. 



AIR AND EXERCISE. 59 

We may leave such arguments as these, and attend to the ex- 
perience of Dr. John Clarke and Dr. Merriman, who have been more 
conversant with the habits and diseases of children than most of their 
contemporaries. The former observes: "It is a subject of very com- 
mon observation, that children who have been inured to cold and 
brought up hardily (as it is called), are the strongest in adult 
age; and this has induced many parents to expose their children, 
thinly clad, to all the severities of weather. It is in part true, since 
children who survive the seasoning are generally strongest. The 
original strength of their constitution probably enabled them to bear 
it in the first instance; and if they are able to encounter it in early 
life, they will lose in some measure the susceptibility of being readily 
affected by changes of temperature afterwards. But all medical men 
who have had opportunities of attending much to the diseases of children 
must have observed that those families in which children are least ex- 
posed to cold in winter are generally most healthy, whilst those who 
act on the erroneous principle of hardening them, by the exposure of 
their tender bodies to severe weather, are scarcely ever free from 
disease of some kind. Disorders which might otherwise have re- 
mained dormant are thus brought into activity by this mode of treat- 
ing children; and many fall sacrifices to pulmonary consumptions and 
scrofulous complaints in more advanced life, from this error alone, of 
being exposed in childhood to cold with the intention of being made 
strong and hardy. The present fashion of clothing young children, 
founded upon the same erroneous notion of hardening them, is also 
very injurious to their health. Their arms and chests are entirely 
uncovered. They generally wear no stockings at all, and from the 
stomach downwards they are almost in a state of nakedness even in 
winter." 1 Dr. Merriman remarks: "I am afraid that Dr. Underwood's 
strongly expressed opinion of the absolute necessity of inuring very 
young infants to endure the cold air, as essential to their health, sup- 
ported as it is by other popular writers, has been productive of great 
and extensive mischief." "True it is that some very robust infants 
endure the cold in a very remarkable manner, and these are often 
quoted as examples of the benefit to be expected from the hardening 
system; but a wise man will be cautious how he follows that as an 
example, which is mentioned only because it is extraordinary. The 
rules which are to guide our practice should be drawn from what is 
usual, not from what is uncommon ; yet we are too often led away to 
imitate what is marvellous and despise that which is more accordant 
with nature's laws and precepts. Thus, on the evidence of one strong 
vigorous infant, the hardening system is applauded and adopted, and we 
neglect to inquire what numbers have sunk into the silent grave, in the 
vain attempt to render them, by exposure to the cold, equally vigorous 
and robust." 2 

70. During infancy the only exercise is of a passive kind, owing 
to the delicacy of the organization at that period ; and yet exercise is 
as essential then as afterwards, and this will be obtained by being car- 

1 On the Diseases of Children, p. 9. z Under-wood, pp. 43, 44. 



60 AIR AND EXERCISE. 

ried about the room in the nurse's arms, not sitting up, for which its 
back and neck are too weak, but in a horizontal or reclining position. 
When the child acquires sufficient strength, it may be allowed to sit 
up, and take its exercise in this posture. The nurse should be ac- 
customed to carry the infant on either arm alternately, for otherwise 
it may acquire a species of deformity from the habit of leaning always 
to one side. Another kind of exercise highly useful to infants consists 
in gentle friction to the back and limbs, which may be applied night 
and morning in the nursery, taking care that there is no undue exposure 
to cold. 

A very common custom of giving the infant of some weeks old exer- 
cise, is by tossing or hoisting it, and no doubt most children like it very 
well, but care should always be taken not to do it too violently, as great 
mischief may result. Moderate tossing, with a gentle, equable motion, 
and swinging backwards and forwards, is both pleasant and useful, if it 
be continued for a few minutes only at a time. 

I agree with Dr. Combe in strongly objecting to the nurse lifting the 
infant by the arms, as is so commonly done. The sockets of the joints 
are very shallow in infancy, and the bones so feebly connected together, 
that dislocation or even fracture may be the result. The nurse should 
place a hand on each side of the chest, under the armpit, and so raise 
the infant. 

71. When the infant is a few months old, it will voluntarily ex- 
tend its exercise by an almost constant movement of its limbs, in 
which it evidently finds great delight. At this time it may be laid 
on a bed, sofa, or on the carpet, and allowed to exercise and amuse itself; 
the comfort of a habit of this kind will be equal to the mother and 
infant, and nothing will so tend to induce a child to creep about. I have 
remarked that children who commence progression by creeping suffer 
far less from falls afterwards than those who commence by walking with 
assistance. 

When assistance is afforded it should be done very cautiously, so as 
not to induce the child to make exertions beyond its strength, nor to 
prolong them too much. 

Dr. Combe observes very truly, that, left to creep about by itself, 
"the infant will be much better strengthened, and learn to walk much 
sooner, and with a more free and erect carriage, than if prematurely 
set on its feet and supported either by the arm or by leading strings. 
The chest, also, will be more fully developed, and the whole system 
consequently benefited. With moderate caution on the part of the 
attendant, there is nothing to fear in thus indulging the infant, for it is 
even amusing to see how careful it generally is about its own safety, 
when left to itself. When a mother takes the entire charge of the 
exercise of an infant, and judges of its risks by her own excited feelings, 
she is sure to err. But remove all external sources of injury and leave 
the child to its own direction, and it will very rarely hurt itself by its 
own procedure. It will crawl till its bones become firm enough to 
bear the weight of the body, and its muscles powerful enough to move 
them." 1 

1 On the Management of Infancy, &c, p. 2G9. 



AIR AND EXERCISE. 61 

72. Mothers and nurses are so proud of a child being able to walk at 
an early age, that they are apt to place them on their feet and (with 
more or less support) keep them moving about in that way before the 
legs have acquired sufficient strength ; and in many cases the result is 
actually to defer the period of walking alone, and perhaps to give a 
curve inwards or outwards to the legs. We may be very certain that, 
when a child is able to walk, he will show his ability in a way that 
cannot be misunderstood, and then a little help, rather to enable him 
to balance than to support himself, will be sufficient. Remembering 
that walking alone requires not merely physical strength but the power 
of balancing, we should be cautious of forcing a child to step alone 
until the latter as well as the former has been acquired. Timid chil- 
dren attain the latter very slowly, and if they are forced, the fear of 
falling will prevent their making the attempt, and will only serve to 
distress them. I would say, then, that the child should itself decide 
upon the different steps of its progress ; and a little watchfulness on the 
part of the mother or nurse (if she be a mother) will easily discover the 
indications. 

It is, of course, necessary to watch that the child do not hurt itself 
in its earlier efforts, and as far as possible to guard against falls ; but 
over-anxiety on this point may injure the child by destroying his con- 
fidence. A few falls on the ground will do no great harm, and will 
probably convey a useful practical lesson to the infant. Certain it is 
that, left to themselves, they do display a wonderful degree of care and 
judgment in taking care of themselves. " An instance is given of a 
child (in the backwoods of America) under a year old being seen 
crawling on all fours along a sadly mutilated bridge, with a roaring 
stream flowing under, within sight of the mother's house, where she 
was quietly engaged in washing, and not troubling herself about the 
apparent danger which startled the traveller so much. On the latter 
expressing his alarm, the mother quietly replied, that the child was ac- 
customed to take care of itself, and knew well what it was about ; and 
then made him observe the deliberate and cautious way in which it made 
even the slightest movement ; adding that, to run anxiously to its as- 
sistance, would be the sure way to frighten it and make it drop into 
the water. There may be exaggeration in this anecdote, but assuredly 
the principle upon which the mother is stated to have acted is sound, 
and might advantageously be carried out in practice much further than 
it has ever generally been." 1 

Such exercise as I have described, with a walk once or twice a day, 
when the weather is fine and temperate, or a change of apartments when 
the weather is unfavorable, will be sufficient during the first twelve or 
eighteen months. 

73. But as the child increases in strength, air and exercise become 
even more indispensable ; in fact a child from two to ten or twelve 
years will be almost always in motion, and cannot have too much fresh 
air, provided there be no undue exposure. The child should be allowed 
(within certain wide limits) to choose the mode and amount of exercise ; 

1 Combe on the Management of Infancy, p. 272. Eberle on Diseases of Children, p. 50. 



62 AIR AND EXERCISE. 

if unrestrained, he will rarely exceed the bounds of reasonable fatigue, 
and a free unfettered use of each portion of the body will best promote 
health and gracefulness of carriage. I scarcely know anything more 
unnatural than the strings of unfortunate school-children taken out to 
walk for exercise, and obliged to put in practice the orthodox rules of 
turning out the toes, keeping the step, walking uprightly, and holding 
up the head ; and at the time envying every little child whom they see 
scampering about as nature intended. 

If, however, the child be too delicate to take sufficient exercise on 
foot, it may obtain both air and exercise, the more necessary on account 
of its delicacy, by means of a donkey or pony, with amusement and 
gentle excitement in addition. Exercise on horseback is particularly 
good for children of both sexes with delicate lungs, as they grow older; 
not merely do they obtain an equal amount of air and exercise, but 
they breathe purer air, and derive peculiar benefit from passing rapidly 
through it. 

74. Up to a certain period girls and boys share their plays and exer- 
cise, and walks, together, and it is far better that the former should be 
allowed as much liberty as the latter, than that they should be prema- 
turely confined. The time, however, will come when the association of 
brothers and sisters will, to a great degree, be broken. Boys, how- 
ever, will obtain sufficient air and exercise for themselves, and even the 
madness of parents for the precocious advancement of their sons will 
hardly obstruct this. Any one who is so deluded as to force forward 
the intellect of his son should remember that he can only do so at the 
expense of health; that the deprivation of adequate air, exercise, and 
play, will be followed by a delicate, enfeebled manhood and probably by 
a premature death. 

But little girls are more frequently victimized. From the moment 
of her separation from the sports of childhood, the great object is to 
make a little woman of her. Her mind is crammed and confused, with 
a little of every kind of knowledge ; and her body cramped and con- 
fined by stays and the endeavor to maintain a womanly carriage ; and 
her feet are cased in tight shoes, so that the pleasure of free movement 
is not only forbidden but destroyed. And the result is not grace but 
formality. Grace cannot exist without freedom, and the tutored effort 
to be graceful or ladylike is necessarily destructive of success. 

Little girls, as they grow up, may very properly be restrained from bois- 
terous plays, but at the same time free air and exercise should be secured 
fur them, without the inconvenience of tight dress. A brisk walk, a 
race after a hoop, or a canter on a pony, will give bloom to the cheek, 
and brightness to the eyes ; and the structure of the body being well 
developed and allowed free play, easy and natural grace will be the 
consequence. 

One word as to the exposure of the child to light. Light is the 
natural food of the eye, and within certain limits it is pleasant and 
agreeable, but it requires regulating according to the age. During early 
infancy the eyes should not be exposed to a concentrated or strong 
light. The light of the sun may be tempered by window-blinds, and 
the infant need not be held near to a lamp or candle. But after a while 



SLEEP. 63 

the eye becomes accustomed to light, and whilst we still avoid the ex- 
treme I have mentioned we should equally avoid the opposite. A dark, 
dull room, or one from which light is more or less excluded, is injurious 
to the eyes, health, and spirits, of children. 

"Every one is aware," says Dr. Combe, "that vegetables are 
blanched by the exclusion of light, and that corn, growing even under 
the shade of a tree, is paler, sicklier, and later in ripening, than that 
growing in the open field ; but we do not keep sufficiently in mind 
that on man the operation of light is scarcely less striking. Deprived 
of its wholesome and enlivening stimulus, he becomes pale and sickly in 
appearance, his blood is imperfectly oxygenated, and a proneness to 
disease of debility arises. Of these results we find numerous examples 
in the narrow lanes and dark cellars of every large town, and in the 
members of the sedentary professions, and others rarely exposed to the 
full light of day ; and especially in children we see them all in an ag- 
gravated degree." 1 

Plenty of cheerful light, when the child is awake, then, is essential, 
and it is equally so to moderate or exclude it during sleep. Too much 
light then will not merely prevent or interrupt sleep, but may act as a 
very injurious stimulus to the eyes and brain. 



75. For some weeks after birth an infant's life is divided between 
feeding and sleeping ; it awakes when hungry, and falls asleep again 
when satisfied ; and in this there is a great advantage, not merely by 
facilitating digestion, but by the repose afforded to the brain and nerv- 
ous system. There should be no attempt to interfere with this, for 
the more the infant sleeps the better ; but by degrees its wakeful mo- 
ments lengthen, and, as it is very desirable that these should occur 
during the day rather than the night, some little effort may be made to 
attain this. 

At first, and for some months, the child should sleep with its mother, 
both on account of the greater warmth to itself, at a time when it needs 
it most, and for the convenience of the mother, who is thereby saved 
the necessity of rising to attend to her child. This, at least, is the 
natural way, and unless there be some special obstacle, I should regard 
it as an imperative duty, although it is a very common practice to let 
the nurse-maid take the infant to the nursery, and feed it during the 
night, from a dislike, apparently, to be disturbed. As for any danger 
to the child which the mother may fear, that clearly must be greater 
with a hireling than with the mother, whose maternal instincts are on 
the watch. If the infant be placed with its head resting on its mother's 
arm it is all but impossible that it should slip down, or be in any danger 
of being overlaid. Care should be taken not to cover it too heavily 
or too closely with the bed-clothes. 

As the child grows older, it may be left in its cradle the first part of 

1 On the Management of Infancy, &c, p. 147. 



64 SLEEP. 

the night, until it requires to be nursed, and then be taken into bed to 
its mother ; but when weaned it should be accustomed to sleep altogether 
by itself. 

76. The head of the cradle should be lined, to guard against draughts 
of air, and the bedding should be warm and soft, without being too 
soft, or the bed-clothes too heavy or too warm. The infant should be 
carefully placed on its side, with its limbs free and its face uncovered, 
so as to allow free access of air. The less effort that is made to put 
the child to sleep the better ; when sleepy, it will generally be suffi- 
cient to place it in the cradle or bed, and keep the room still and dark. 
Without precisely objecting to rocking or hushing the infant to sleep, 
I have no hesitation in saying, that much trouble is saved to child 
and nurse by accustoming it to go to sleep without it, and because it 
is placed in bed. Young children are so completely creatures of habit, 
that anything may be taught them, and it is better that they should 
be taught good and regular habits than the contrary. The advan- 
tage of the plan of which I am speaking is seen peculiarly during 
sickness, when the child will be fretful, and require much more 
than the ordinary coaxing to sleep, if it have been accustomed to it 
at all. 

Gradually the amount of sleep during the day diminishes, but for 
three or four years a child is greatly benefited by an hour's sleep in the 
middle of the. day, and this is a habit which should be encouraged and 
prolonged as much as possible ; for during waking hours children expend 
far more vital energy than adults, and a midday sleep recruits them, 
and prevents them being over-fatigued and fretful in the evening. For 
this reason, also, children should be put to bed early ; during the first 
year or two, half-past five, or six, and for five or six years more, seven, 
or half-past, is quite as late as they ought to be allowed to stay up : 
the worn, weary look of children who sit up late is a sufficient proof of 
its injurious effects. 

Besides, children are morally and physically the better for acquiring 
early habits ; but a child cannot rise early who goes to bed late. Ten 
hours' sleep are barely enough for a night's rest for a child, and no- 
thing should induce parents to shorten a child's full allowance of it. 
For this reason a child should not be awoke in the morning, but simply 
sent to bed earlier at night, and it will awake itself. Once awake, it 
should, if possible, be washed and dressed immediately, as lying in bed 
awake merely promotes indolent habits, without any benefit to the 
health. Regularity of habits may be applied to sleeping quite as much 
as to eating or any other natural operation, and it is no less desirable 
for the comfort of mother and child. 

But what is to be done when the child is restless, and will not 
sleep ? we are often asked. Can you not give it something to make it 
sleep ? Certainly ; but the question is, ought you to do so ; and I would 
unhesitatingly answer in the negative. At proper intervals, it is na- 
tural for the child to sleep, and it will do so if there be nothing pre- 
venting it ; our duty, therefore, is, to find out the obstacle and remove 
it. The child may be placed uncomfortably in bed ; there may be un- 
due pressure upon some part; the bed may be rough and uneven; its 



MEDICINE. 65 

feet may be cold ; it may have eaten too much ; or it may be teething. 
Any of these circumstances "will make the child fretful and restless, 
and they must be relieved ; if none of them exist, the child must be 
unwell, and should be treated accordingly, but not dosed with laudanum, 
syrup of poppies, Godfrey's cordial, or any of the mischievous remedies 
which nurses are too ready to employ. If the child be really restless 
and uneasy, without ascertainable cause, it may be put into a warm 
bath for a few minutes, which will soothe it, and often cause it to fall 



When the child is up and dressed, its night-clothes and bed-clothes 
should be exposed to the air, as the effect of fresh coverings is ex- 
tremely soothing and healthful. 



MEDICINE. 

77. Very few words will comprise all I have to say on this matter, 
because I think that the less medicine a child takes the better for his 
health ; i. e., so long as the child is in health, the natural functions will 
be performed, according to his constitution, without medicine ; and if 
the child be sick, the less tampering with medicines by mother or nurse 
the better. A mistake has arisen from the notion that the constitution 
of all children is alike and that their evacuations ought to be alike, 
whereas nothing can be more erroneous. An infant's bowels are moved 
four or five times a day ordinarily, gradually diminishing in frequency, 
as the child grows older, to three, two, or one evacuation per diem ; 
but we are not to insist upon this as an invariable rule, and administer 
medicine until it is complied with. In the case of one of my own 
children, and one of the most healthy, the bowels, after the first few 
weeks, were only moved once a day, and he took no medicine from the 
first dose of castor oil until he was nine months old, nor had he one 
hour's sickness. 

A dose of castor oil is usually given at birth, and may be repeated, 
if necessary, until the meconium is cleared away. After that, nature 
should be allowed fair play, and medicine should not be given unless 
there be sufficient reason. If the child appears uneasy and hot, and 
the bowels are confined, a dose of oil or rhubarb may be given, or a 
warm bath ; but if the child exhibit no signs of suffering, why should 
we interfere ? 

There is, however, one exception to this rule, and that is, when the 
child is teething; at this time a certain amount of irritation is excited, 
which, if it localize itself in any organ, may prove highly injurious. 
The most common and least mischievous accompaniment is a bowel com- 
plaint, and, to prevent a worse evil, it is advisable to determine to the 
bowels by an occasional dose of medicine. 

78. To children who suffer much from flatulence, a litttle fennel 
water or caraway seed water, with sugar and plain water, may be given ; 
or a carminative composed of rhubarb, magnesia, syrup, and aniseed or 
caraway seed water. Beyond these, the nurse should be allowed the 
command of no medicine whatever, unless ordered by the medical at- 

5 



bb THE NURSERY AND NURSES. 

tendant ; nay more, she should be absolutely prohibited from having 
any in her possession, for it is not unusual for her to provide herself 
with a little Godfrey's cordial, syrup of poppies, or even laudanum, 
and administer it for the purpose of quieting the child, and avoiding 
the trouble of rising in the night. Dr. Dewees remarks: "Nurses 
generally make a point to have a certain period of the day at their 
command ; and should they find this hour repeatedly interfered with 
by the wakefulness of the child, they will soon have recourse to such 
means as shall prevent its future recurrence. We have known a num- 
ber of cases where laudanum was administered for this purpose, with so 
much cunning as to elude detection for a long time, even after the sus- 
picion had been excited. In one of these instances, the wily nurse 
boasted to the abused parent of her good management in establishing 
so much regularity in the child's sleeping." 1 



THE NURSERY AND NURSES. 

79. So much of the health and comfort of children depends upon 
the nursery and their attendants, that I cannot omit a few words upon 
each. As the infant will spend a considerable portion of its time for 
the few first years in the nursery, its situation and suitability cannot 
be a matter of indifference. Plenty of fresh, pure air and light is the 
first requisite, but this will of course depend upon the situation of the 
house. In the country it is easily obtained, but in towns other cir- 
cumstances determine in a great measure the choice of a house. The 
choice of a room for the nursery, however, is in our power, and any 
sacrifice should be made to secure one which may promote the health 
of those who are so dear to us. It should be large, airy, light, well 
ventilated, and easily warmed. Generally speaking, the upper room in 
the house is the best ; it has freer access of air, and more light and 
greater cheerfulness. 

It should be neatly papered and painted, and so arranged that 
perfect order may be. preserved. Just so much furniture should be 
allowed as is necessary, and no more, as the more space without ob- 
struction for the child to play about the better. The beds should be so 
placed as to be easy of access, and they should be provided with partial 
curtains, just enough to shade the eyes from the light. I think the 
light iron bedsteads, with heads and castors, by far the best, for many 
reasons. It is better not to have a carpet, or at most a very small one, 
as it accumulates dust, and is an obstacle to a young child in its early 
efforts to walk. The floor should be scoured once a week, or oftener if 
necessary, and the most minute cleanliness and order observed about 
everything used in the nursery. 

After dressing in the morning, it is very desirable that the children 
should all leave the nursery for an hour, during which time the win- 
dows and door should be opened, so as to secure perfect ventilation 
after the night, and a fresh, wholesome room on their return, and this 

1 On Diseases of Children. 



NURSES. 67 

should be repeated occasionally during the day, when they are ab- 
sent. 

80. The temperature must be regulated according to the season and 
the aspect of the house ; it should range somewhere between 60° and 
70°. During winter, and a portion of spring and autumn, a fire will be 
necessary during the day, but not during the night, unless in case of 
sickness, and care should be taken that the nurse, for her own enjoy- 
ment, does not make it too large. During summer, if the room be 
exposed to the sun, it will become warm enough, but if there be any 
doubt, it is better to have a little fire, as warmth is essential to the com- 
fort and health of children. 

" From pure ignorance on the part of the parents, it is also a common 
practice not only to crowd several children and one or two nursery 
maids into a small room, but to allow cooking, washing, and other 
household operations connected with the nursery, to be carried on in it. 
Nothing, however, can be more injudicious, or more directly at variance 
with the duty of parents to promote to the utmost the welfare of their 
offspring." " If the size of the house will admit of it, the day nursery 
should always be separate from the sleeping one. Wherever one or 
two persons sleep the air is always considerably contaminated before 
morning, and the impurity is of course so much the greater where, as 
is often the case, several children sleep in the same apartment. If 
there is only one bed-room, it is impossible to remove the impurity by 
adequate ventilation, because even in summer the draught from the 
open windows is attended with risk, and during at least two-thirds of 
the year in this country the cold and damp of our climate would render 
it utterly impracticable to keep them open for a sufficient length of 
time. But the case is altogether different when there is a day room in 
addition. The children can then be removed from the vitiated air and 
impurity of their sleeping apartment into a wholesome and bracing at- 
mosphere, and the bed-room be thoroughly cleaned, the bed-clothes and 
everything else well aired, and the room itself effectually ventilated, 
without risk to any one." 1 There can be no doubt of the advantage of 
this plan, but it is not often practicable in towns, where the family is 
large ; and in such cases, if the children be allowed to descend to the 
parlor in the morning, after being washed and dressed, the nursery may 
be very well ventilated in half an hour. 

I would repeat that cleanliness and order ought to be rigorously en- 
forced in the nursery, not merely for the sake of health, but as a part 
of the practical education of children. 



NURSES. 

81. Considering how many hours, days, and weeks children spend 
alone with their nursery attendants, and also the extreme impressibility 
of early life, it is certainly surprising that more care is not bestowed 
on the selection of a nurse and nursery maids than we usually find. 

1 Combe, p. 61. 



68 NURSES. 

First impressions are the strongest, and especially when those are evil ; 
and I have no doubt that much of the trouble that parents experience 
in the moral government of children might be traced to the lessons, 
practical and verbal, that they have received in the nursery. Habits 
of irregularity, disorder, equivocation, and self-indulgence, are daily 
taught them by example ; and if they be discouraged by precept, -we 
know that the former lessons are far more permanent. Evil words and 
selfish actions leave an impression long after their source is forgotten. 
I have often heard parents express their astonishment at vulgar habits 
and low expressions from their children, who never thought that they 
were indebted for their acquisition to themselves, through the nurses 
they had chosen. The nurse who has the charge of the children, or 
the principal nurse, if there be more than one, should be a woman of 
middle age — if possible one who has been a mother herself — and some- 
what above the station of a servant, so as to secure better education 
and better manners. She ought to be upright, kind, and religious, for 
she who has not reverence towards God is utterly unfit to mould the 
character, or govern the habits, of young children. Her temper should 
be mild, cheerful, and forbearing, for the management of children 
may tax her good nature severely, and yet if she give way to irrita- 
tion she may injure the child's temper irretrievably ; and cheerfulness 
is so much the character of childhood, and so necessary for mental and 
moral health, that a nurse would be essentially deficient in whom it was 
absent. 

A love of truth and an abhorrence of lying in any form, whether in 
the shape of excuses, deceit, concealment, or falsehood, is essential, 
unless we wish the ruin of children, for they will learn from the actions 
of the nurse rather than from her precepts, and the instruction of a 
wise mother will be entirely thrown away, if counteracted by the con- 
duct of the nurse. It will also be a great advantage if she be able to 
read and write. I need not dwell upon the necessity of habits of order, 
cleanliness, and personal tidiness ; these are hardly likely to be over- 
looked by a careful mother, although she may not appreciate their 
influence upon the habits and character of her child. 



PART II. 



THE 



DISEASES 



INFANCY AND CHILDHOOD 



Thk plan I propose, in each section of the present division of the work, is, first, to 
notice the diseases by which the foetus is most frequently attacked during the intra-uterine 
life; then to treat of those which it presents to us at birth, whether of long standing or 
acquired during childbirth, together with certain malformations which require treatment; 
and lastly, to enter at length into the consideration of the diseases which affect infancy 
and childhood. These I propose arranging neither according to the period of life at 
which they occur, nor according to their pathological characteristics, but simply accord- 
ing to the systems affected, so far as this can be done ; thus grouping together diseases of 
the nervous, respiratory, digestive systems, &c. &c. Whatever may be lost, in a scientific 
point of view, by this arrangement, will, I trust, be more than compensated by the prac- 
tical advantages of exhibiting the morbid conditions of organs in their systematic rela- 
tions. Afterwards, I shall treat of fevers, and other affections which do not admit of 
much classification. 



SECTION I. 



DISEASES OF THE CEREBROSPINAL SYSTEM. 



CHAPTER I. 

INTRA-UTERINE OR CONGENITAL DISEASES. 



CONVULSIONS. 



82. Many authors have maintained that the foetus in utero is sub- 
ject to epileptic or convulsive attacks. Duettel states : " Nullus autem 
affectus familiaria solet esse proli in utero quam epilepsia." And 
Segerus relates a case of a pregnant woman who suffered severely from 
this disease, and in whom the foetus exhibited similar convulsive move- 
ments. 1 Lowenheim held that it was not uncommon, and Hoogeveen 
and Feiler relate examples. Hufeland thinks that these convulsive 
movements are dependent upon, or derived from, the mother. 2 

There are few practitioners of any standing who have not been con- 
sulted on account of the distress caused by the violent movements of 
the foetus ; in many cases the annoyance arises from excess of uterine 
sensibility, but in others the movements appear to be excessive, irregu- 
lar, and of temporary duration, subsiding after a time, to return in 
moderate degree, or to recur again in paroxysms, or perhaps to cease 
altogether. Such cases I have several times observed, and in the lat- 
tar instances the child has been stillborn, and the period of its death 
referred to the close of the violent convulsive movements. In a case 
of this kind, where the death of the child corresponded to the mother's 
perception of the convulsive movements, Dr. McSweeny found, on 
dissection, that the membranes of the brain were greatly injected. 
Whether these are cases of epilepsy may of course admit of a question, 
but it is of little consequence, as during intra-uterine life nothing reme- 
dial can be attempted. 

HYDROCEPHALUS. 

83. The occurrence of hydrocephalus in the foetus is not a discovery 
of modern times. Thus Blancard relates a case of a foetus of seven 

1 M. N. C. Dec. 1, An. 3, Obs. 160, p. 291. 

2 Graetzer Die Krankheiten des Foetus, p. 259. 



72 INTRA-UTERINE OR CONGENITAL DISEASES. 

months, where a large quantity of water was found between the dura 
and pia mater j 1 and Russeus another, where the head was so distended 
with fluid that it weighed more than the rest of the body. 2 Lechelius, 
Schurig, and Hoogeveen give similar cases. In more modern times the 
disease has been described by Voigtel, Meckel, Otto, Alibert, Rudolphi, 
and as an impediment to delivery, by almost all midwifery authors. It 
is not very uncommon among the lower classes ; I have seen at least 
five or six cases. 

Some writers have attributed it to an arrest of development, but 
Rudolphi considers it 3 to be a- special disease, arising from excessive 
congestion of the membranes, or from inflammation. Another view of 
the origin of this disease, which has been put forward by Breschet and 
Behrend, is, that it consists in an excess of the fluid which exists 
naturally in the cavities of the brain, as was noticed by Cotunnius, 
Morgagni, Magendie, &c, and called by the latter the cerebro-rachidian 
fluid. This fluid may either be confined within limits, or by its pres- 
sure may produce encephalocele, hydrencephalocele, or spina bifida. 
I shall have to notice this view again when speaking of chronic 
hydrocephalus, and therefore shall only state that I think it offers a 
reasonable explanation of a portion of these cases. During foetal life, 
of course, we can obtain no evidence of its existence. In many cases 
the foetus is dead before birth ; in others, when the fluid is considerable, 
it has to be destroyed even if alive, in order that labor may be com- 
pleted ; and in very few cases is the child born alive. Should the dis- 
ease not have proved fatal, and the enlargement of the head be so 
moderate • as to permit of its transit through the pelvis without an 
operation, then the treatment will be that of chronic hydrocephalus, of 
which I shall speak hereafter. 



ABSENCE OF BRAIN OR SKULL. 

84. Examples of an arrest of development in the brain or cranial 
vault may be seen in every museum, and many plates of such cases are 
given by Geoffroy St. Hilaire in his learned work on monsters, and by 
other authors who have entered fully into the many interesting ques- 
tions depending thereupon, and to whom I must refer my readers. 4 It 
is enough for my purpose to state, that the brain and skull are more or 
less defective in such cases. I have one preparation in which the brain 
presents the appearance of a bunch of tumors ; another where a por- 
tion only of the brain exists ; and a third where it is entirely wanting ; 
and in all the cranial vault is absent, the base of the skull alone re- 
maining. 

That these are cases of arrest of development, and not the result of 
disease, can admit of no question ; and that they afford a wide field of 
physiological investigation, which has been but partially explored, is 

1 Collect. Phys. Med., Cent. i. Obs. 75, fol. 65. 

2 De Extract. Foetus, cap. 23, 1562. 

3 Abhandl. der Konigl. Acad, zu Berlin, 1824, p. 121. 

* See the article Anencephalie in Diet, de Med. et de Chir. Prat., vol. ii. p. 377. 



INTRA-UTERINE OR CONGENITAL DISEASES. 73 

equally true. This malformation does not necessarily prohibit the full 
growth and development of the foetus, nor its being born alive and 
apparently healthy, but it seldom lives more than a day or two. In 
one case which occurred at the Western Lying-in Hospital, the child 
was large and healthy, but it had neither brain nor skull, except the 
base, and it had cleft palate and double hare-lip. It lived two days. 
Formerly it was considered right to destroy such monsters ; under the 
wiser legislation of modern times it is considered to be criminal, and 
punished accordingly. 



HERNIA CEREBRI. — ENCEPHALOCELE. 

85. This malformation is also due to an arrest of development in 
the ossification of the cranium, by which the fontanelles and sutures are 
left incomplete, or to the pressure of the cerebro-rachidian fluid in con- 
sequence of which the bones are separated or perhaps absorbed. It has 
been called podencephalie by Geoffroy St. Hilaire, when the deficiency is 
at the upper part of the cranium, and notencephalie, when the arrest 
takes place posteriorly. Through the space thus left the brain protrudes, 
forming a tumor above or behind the head, covered in the majority of 
cases by the integuments. The tumor is soft, rounded, and pulsating in 
accordance with the pulse, yielding to pressure and disappearing, with- 
out discoloration of the integuments, and circumscribed at its base by 
the defective bone. The size will vary according to the amount of brain 
which escapes through the opening; those which are situated superiorly 
at the anterior fontanelle appear to be the smaller. Sanson mentions a 
case in which the entire brain escaped by a round opening correspond- 
ing to the posterior fontanelle; the infant lived fifteen hours, and its 
functions were all naturally fulfilled. 1 

86. If the sutures be very defective, the cerebellum may protrude. 
" B In 1813 two such cases occurred at Paris. In one, Professor Lalle- 
ment mistook the disease for a common tumor, and commenced an 
operation for its removal, when, after making some of the necessary 
incisions, his proceedings were stopped by his seeing the white silvery 
color of the dura mater, and that the swelling came out of an aper- 
ture in the occipital bone. The day after the operation the child was 
seized with violent pain in the head, had a hard pulse, prostration of 
strength, vomiting, &c, and died in the course of the week. On dissec- 
tion, a part of the tentorium and an elongation of the two lobes of the 
cerebellum about as large as a nut, were found in the protruded sac of the 
dura mater. Several abscesses were also discovered in the substance of 
the cerebellum. 

"The other example fell under the observation of M. Baffos ; upon the 
death of the child the dissection evinced similar appearances." 2 

A more remarkable instance of cerebral hernia is mentioned by M. 
Sanson as having been observed by M. Serres, in which the brain pro- 

1 Art Hernie, Diet, de Med. et de Chir. Prat., vol. ii. p. 496. 

2 Cooper's Surgical Dictionary, Art. Hernia Cerebri, p. 754. 



74 INTRAUTERINE OR CONGENITAL DISEASES. 

truded through a fissure in the base of the skull, and projected into the 
pharynx. 

87. But though in the greater number of cases the skull alone is 
deficient, the integuments covering the tumor are perfect, yet in some 
cases there is a deficiency more or less of the integuments of the head. 
This occurs most frequently about the posterior fontanelle, and then 
the brain hangs like a bag at the back of the neck. The children 
are generally stillborn. Richerand mentions that several such ex- 
amples are preserved in the museum of the Faculty of Medicine at 
Paris. 1 

A curious case of more extensive deficiency, both of bones and inte- 
guments, was published in 1810 by Dr. Burrows: "The whole of the 
forehead, summit, and a great part of the occiput, were deficient, and 
instead of them a substance projected, of a light mulberry color and of 
the mushroom form, except that it was proportionably broader. From 
the deficiency of bone the eyes appeared to project much more than 
usual." 2 On dissection, the scalp, os frontis, the parietal, and a great 
part of the occipital bones, were wanting. Through the parts at which 
these bones were deficient tti£ cerebrum projected, exhibiting its usual 
convolutions. It was covered with the pia mater, was of a mulberry 
color, appeared to be more vascular than the pia mater usually is, and 
the edge of the scalp adhered to the neck of the tumor. The cerebellum 
was not more than one-fourth of its usual size, for the posterior part of 
the os occipitis was much nearer to the cella turcica than natural. The 
child was destitute of the power of voluntary motion, and all the secre- 
tions appeared to* be stopped. 

This case resembles a good deal the case I have already (84) men- 
tioned, in which the vault of the cranium was absent, and the brain 
and cerebellum, inclosed in (apparently) the dura mater, was divided 
into several round tumors, the size of small potatoes. These cases, 
however, strictly speaking, scarcely come under the definition of 
hernia. 

88. Diagnosis. — The only diseases with which congenital encepha- 
locele might be confounded are cephalhematoma of the scalp and acci- 
dental tumors; but a little care will generally be sufficient to enable 
us to distinguish them. Hernia cerebri is almost always in the line 
of the sutures, where a space is left from the arrest of bony growth: 
cepbalgematoma, on the contrary, are very seldom indeed, and then 
only partially, situated over the sutures or fontanelles; formed by 
pressure of the os uteri, and increased by the pressure of the os exter- 
num, they will always be found on the exact part which presented, 
and in no case is any suture more than slightly involved in the pre- 
sentation. Moreover, in hernia, the absence of bone beneath the tu- 
mor can be ascertained; and in cephalaematoma, although the circular 
ridge gives at first a feeling of there being a perforation, yet on press- 
ing the swelling on one side, the unbroken surface of bone may be 
felt. Lastly, there is a constant pulsation, synchronous with the pulse, 

1 Nosographie Chirurg., vol. ii. p. 316. 

2 Med. Chir. Trans., vol. ii. p. 52. 



INTRA-UTERINE OR CONGENITAL DISEASES. 75 

in hernia, and the tumor can be depressed to the level of the skull; but 
in cephalsematoma there is no pulsation, or an uncertain one commu- 
nicated from the fontanelle, and the tumor does not disappear under 
pressure. 

The situation of the tumor, the absence of cranium underneath, the 
marked pulsations, and its disappearance under pressure, will distin- 
guish hernia from any other kind of tumor which is formed upon the 
scalp. 

89. Treatment. — All writers, I believe, are agreed that the best 
mode of treatment consists in the application of gentle and equable 
pressure. M. Salleneuve used a piece of thin sheet lead, softly padded, 
and fastened to the child's cap at the part corresponding to the tumor, 
and the pressure was increased or diminished by tightening or loosen- 
ing the cap. By thus depressing the tumor gradually, and without 
injury, an opportunity is given for the growth of the bone, and the 
completion of the defective space, which of course is the radical cure of 
the hernia. M. Salleneuve related to the Royal Academy of Surgery 
of France, a case which was thus cured. 1 Callisen and Sanson concur 
in the propriety and feasibility of this mode of treatment, when the 
tumor is small ; but when it is large, and at the occiput especially, 
little more can be done than some contrivance to protect it from in- 

When the tumor consists mainly of fluid it may be worthwhile trying 
the effects of puncture, with or without compression. Mr. Lyon punc- 
tured the tumor on the right side of the nose, and afterwards on the 
left side, but the child died. Mr. Adams punctured a tumor seven 
times with success, ultimately leaving a solid tumor, which was appa- 
rently a protruding portion of the brain. Mr. Earle repeated the 
operation nine times, and the child lived two months. And Mr. Dendy 
operated three times in nine days, allowing nearly twelve ounces of fluid 
to escape, but the child died on the tenth day. These instances, however, 
are not very encouraging. 



SPINA BIFIDA. — HYDRORACHITIS. 

90. In some respects this congenital disease bears a strong analogy 
to the one last described, depending either upon an arrest of develop- 
ment in some portion of the spinal canal, or upon an excess of the cere- 
bro-rachidian fluid, which by its pressure first produces absorption of the 
bones, and then protrudes the membranes by which it is surrounded in 
the form of a soft tumor, varying in size from a walnut to a foetal head. 
The most frequent situation of this malformation is in the lower lumbar 
vertebrae, next in the dorsal region, and occasionally in both at once, 
next in the bones of the sacrum, 2 then in the cervical region, and 
lastly, in the lower portion of the sacrum, as in the case published by 
M. Vrolik. 

1 Mem. de l'Acad. de Chir., vol. xiii. p. 103. 

2 Ollivier, Mai. de la Modes Epin., vol. i. p. 184. 



76 INTRA-UTERINE OR CONGENITAL DISEASES. 

The disease consists in a deficiency of the spines and bodies of the 
vertebral canal, and the different degrees have been grouped into three 
classes by Fleischmann and others. 1 

I. When the entire vertebra is divided ; this case is extremely rare. 
Ollivier recites three cases related by Tulpius, Malacarne, and Zuringer, 
in which it existed. 

II. An absence of a greater or less portion of the lateral arches of 
the canal : this is the most common variety. And 

ill. Where the arches are well developed, but without union posteri- 
orly : here, however, the separation can be but a few lines, resembling 
a groove rather than an aperture. Ruysch, Acrell, and Isenflamm 2 
have each described a case of this kind ; the former in the lumbar 
region, the second in the sacrum, and the latter in the first cervical 
vertebra. 

In each class the limit of the deficiency is marked by the edge of the 
bone, sometimes smooth and level, sometimes irregular, and sometimes 
with the edges turned a little outwards. Ordinarily the spines of the 
vertebra share in the malformation, and are divided or altogether ab- 
sent. It must be remembered, however, that the absence of the spi- 
nous processess is no proof of spina bifida. Beclard has found them 
absent several times as a simple malformation, the bodies preserving 
their integrity. 

The tumor, varying in size, and of a round or oblong shape, or occa- 
sionally, as in Mr. Brewerton's case, 3 consisting of two cysts, is gene- 
rally covered by the skin, which, when it is very small, may be of the 
natural color, but which, as the tumor increases, becomes thin, trans- 
parent, and generally marbled with reddish or violet shades. In some 
cases it appears worn through, and the outer envelop has none of the 
characters of the skin, but resembles a very fine vascular membrane, 
which is indeed the dura mater of the cord, beneath which we find the 
arachnoid and the pia mater. Occasionally, though rarely, the dura 
mater is defective, and the arachnoid becomes the external covering. 

The fluid contained in the tumor is generally limpid serum, resem- 
bling that secreted in hydrocephalus, and containing, according to the 
analysis of Bostock, Marcet, and Lassaigne, water, albumen, osma- 
zome, mucus, and salts of potash or soda, in small quantities. It is 
occasionally turbid or tinged with blood. The quantity varies : Siebold 
saw more than a pint escape, Vogel two pints, and Mr. Innes about 
seven pints. 

The condition of the spinal marrow is of considerable interest. Olli- 
vier states that, when the case is not complicated with hydrocephalus, 
he has generally found the spinal marrow traversing the sac unaltered, 
except that in some cases it seems lengthened. 4 But if coexistent with 
hydrocephalus, or if the canal of the spinal marrow be distended with 
fluid, the cord may be flattened out, as it were, so as apparently to line 
the sac. 5 Or, either from the extreme distension or from some morbid 

1 Vitiis congenitis circa Thoracem et Abdomen. Erlangen. 

2 Arch. G6n. de Med., vol. iv. p. 299. 

3 Edin. Med. and Surg. Journ., vol. xvii. 4 Op. cit., vol. i. p. 197. 
6 Duges, Diet, de Med. et de Chir. Prat., vol. s. p. 138, Art. Hydro-raehis. 



INTRA-UTERINE OR CONGENITAL DISEASES. 77 

process, the cord may be partially or wholly destroyed, leaving at most 
some shreds or filaments. Ruysch and Greeve observed the remains of 
the cord thin and softened, covered with watery vesicles, and Acrell 
discovered it covered with hydatids. 

In some few cases the spinal cord seems to have left the canal, and 
to be contained within the tumor, forming what some authors have im- 
properly called hernia of the spinal marrow. This happens only when 
the deficiency is at the lower end of the spine. 

91. To the touch the tumor feels soft and fluctuating, and by a little 
care we may detect the deficiency in the spinal canal, at the base, or a 
little underneath the base of the tumor. Pressure upon the tumor causes 
uneasiness, convulsions, or coma. 

The effect of this malformation upon the portion of the body supplied 
with nerves by the lower part of the spinal marrow varies in degree, 
depending, most likely, on the degree of pressure, from within or with- 
out, upon the cord. In almost every case the child has less power than 
usual in its legs; however, Mr. Cooper has related a remarkable excep- 
tion in a child who had one of the largest spina bifidas he ever beheld, 
and which was unattended with any such weakness; "indeed, the child 
was, to all appearance, as stout, healthy, and full of play as possible. 
The fatal event, however, took place after a time, as usual; and a little 
before death a remarkable subsidence of the swelling occurred, which, 
however, never burst externally." 1 

I have seen more than one case in which the infant retained the power 
of voluntary motion, but none that could walk. In other cases, the limbs 
are atrophied and completely paralyzed; and in the worst instances, the 
bladder and rectum are equally affected, and the child can neither con- 
trol the urine nor feces. 

92. The tumor may burst before birth with or without the destruc- 
tion of the child. 2 Generally, however, we find it unbroken, but in a 
few days or weeks the surface becomes inflamed, small patches of super- 
ficial ulceration appear to coalesce, until a large and deepening ulcer 
is formed, which soon perforates the sac, evacuates the fluid, and, by 
exposure of the spinal marrow, occasions inflammation, convulsions, and 
death very shortly; or the opening may be small and fistulous, with like 
results. The age at which this termination occurs varies, although it 
seldom exceeds three years. However, Bonn relates a case that lived 
to the age of ten years; Warner one aged twenty; Camper one aged 
twenty-eight years; and Swagermann mentions an individual thus 
affected who lived fifty years. 3 Mr. Samuel Cooper relates that he saw, 
under the care of Mr. C. Hutchinson, a young woman, nineteen years 
of age, who had a spina bifida, which was of astonishing size, and 
situated at the lower part of the vertical column. One curious circum- 
stance in the case was that the patient used to menstruate through a 
sore in the thigh. I conclude that this is the same case as is described 
by Mr. Innes, and who states the measurement of the swelling to have 
been thirty inches in its vertical line. The urine and feces used to 
pass involuntarily. 4 

1 Surg. Diet., Art. Spina Bifida, p. 1171. 2 Ollivier, dela Mceile Epin., vol.i.p. 200. 

3 Ontleed Heelkund, Verhandl. Amst., 1767. 4 Surg. Diet., p. 1171. 



78 INTRA-UTERINE OR CONGENITAL DISEASES. 

With the exception of the paralysis, so long as the child lives the 
bodily functions continue but little disturbed. I have found the in- 
fant to take its food eagerly and to sleep well until the bursting of the 
tumor. 

But in many cases malformation is not limited to a portion of the 
spine; the bones of the skull may exhibit a similar deformity; the 
bladder may be extroverted, or the child may have congenital hydro- 
cephalus; the fluid in the lateral and third ventricles passing into the 
fourth, through the aqueduct of Sylvius, and rupturing the calamus 
scriptorius, escapes into the vertebral canal. In these cases the volume 
of the head has been observed to diminish after the rupture of the spina 
bifida. 

93. From the details already given it is evident that, though not in 
every case fatal, yet that the prognosis is in all cases unfavorable : so 
few cases escape that we can indulge but little hope of any one in par- 
ticular. In addition to the case of recovery already mentioned, I may 
add that Morgagni, 1 Kielmann, 2 and Jervis, 3 each relate one, and Sir 
A. Cooper two, in which the patients have lived. These are, I believe, 
all, or nearly all, on record; and, without diminishing the serious cha- 
racter of the disease, they just afford a reasonable ground for attempt- 
ing some kind of treatment. 

The symptoms which mark the approach of death are nearly alike 
in all cases. When the opening is small and fistulous, the fluid changes 
its character and becomes turbid, then more or less purulent, and per- 
haps fetid, after which convulsions set in. When the opening is larger, 
inflammation occurs more rapidly, and the convulsions follow speedily. 
The termination is rapid, in proportion as the inflammation extends up 
the vertebral canal. 

94. Treatment. — Various methods of treatment have been proposed 
and tried, but with very little success, as we have seen. Mr. Abernethy 
recommended a slight degree of pressure on the tumor from the com- 
mencement, with the double object of limiting the distension of the dura 
mater, and promoting the absorption of the fluid. Should the fluid in- 
crease, notwithstanding, he proposed to lacerate it by a fine instrument, 
to anticipate its bursting. The wound is then to be closed and allowed 
to heal, and the pressure to be resumed. He tried this plan in one 
case, where ulceration had commenced; the punctures were repeated 
every fourth day for six weeks; the wounds healed very well, until at 
last one of them became ulcerated ; the discharge became purulent, and 
the child died. 4 

Heister mentions a case of compression under the care of a surgeon 
named Steuber. Sir Astley Cooper relates a case of preservation of 
life, though not of radical cure, by compression, which I shall ex- 
tract. "James Applebee was born on the 19th of May, 1807, and his 
mother immediately after his birth, observed a round and transpa- 
rent tumor in the loins, of the size of a large walnut. On the 2 2d 
of June, 1807, the child was brought to my house, and I found that 

1 De Sed. et Oausis, Morb. Epist. xii. Art. 9. 2 Prodrom. Act. Havn, p. 136. 

8 Journal G6n. de Med. 1106. vol. xxvii. p. 162. 

4 Cooper's Surgical Diet., Art. Spina Bifida, p. 1172. 



INTRA-UTERINE OR CONGENITAL DISEASES. 79 

although it had spina bifida, the head was not unusually large, and 
the motions of its legs were perfect, and its stools and urine were dis- 
charged naturally. I applied a roller round the child's waist, so as 
to compress the tumor, being induced to do so from considering it a 
species of hernia, and that the deficiency of the spine might be com- 
pensated for by external pressure. The pressure made by the roller 
had no unpleasant influence on its voluntary powers; its stools and 
urine continued to be properly discharged ; but the mother thought 
that the child was occasionally convulsed. At the end of a week a 
piece of plaster of Paris, somewhat hollowed, and that hollow filled 
with a piece of torn lint, was placed upon the surface of the tumor, 
a strap of adhesive plaster was applied to prevent its changing its 
situation, and a roller was carried around the waist to bind the plaster 
of Paris firmly on the back, and to compress the tumor as much as 
the child could bear. This treatment was continued until the month 
of October, during which time the tumor was examined about three 
times a week, and the mother reported that the child was occasionally 
convulsed. When the child was five months old, a truss was ap- 
plied, similar in form to that which I sometimes use for umbilical her- 
nia in children, and this has been continued ever since. At the age 
of fifteen months it began to make use of its limbs; it could crawl 
along a passage, and up two pair of stairs. At eighteen months, by 
some accident, the truss slipped from the tumor, which had become 
of the size of a small orange, and the mother observed, when it was 
reduced, that the child appeared in some degree dull; and this was 
always the case if the truss was left off for a few minutes, and then re- 
applied. At fifteen months he began to talk, and at two years of age 
he could walk alone. He now goes to school, runs, jumps, and plays 
about just like other children. His powers of mind do not appear to 
differ from those of other children. His memory is retentive, and he 
learns with facility. He had the measles and the smallpox in the first 
year, and the hooping-cough at three years. His head, previously 
and subsequently to the bones closing, has preserved a due proportion 
to other parts of the body. The tumor is kept by the truss entirely 
within the channel of the spine; but when the truss is removed, it soon 
becomes of the size of half a small orange. It is, therefore, necessary 
that the use of the truss should be continued. When the truss is 
removed, the finger can be readily passed through the tumor into the 
channel of the spine." 1 

For success in this operation it is requisite that the tumor be small, 
the skin unbroken, and the disease local and uncomplicated. 

95. Richter has proposed the insertion of two caustic issues at a little 
distance from the tumour, but it does not appear that his suggestion has 
been adopted. 

96. Forestus, in the first instance, and Mr. B. Bell, more recently, 
advised the application of a ligature round the base of the tumor, pro- 
vided the disease be local, and a mere distension by fluid in consequence 
of the imperfection of the bones, and not a disease of the spinal marrow, 

1 Med. Chir. Trans., vol. ii. p. 323. 



80 INTRA-UTERINE OR CONGENITAL DISEASES. 

or membranes, and it be not complicated. It does not appear that either 
of them tried it, but it failed with a case of Heister's. 

97. Dessault 1 and Mathey 2 proposed the insertion of a seton through 
the tumor, but this would be to quicken the ordinary chances of menin- 
gitis by admiting the air. Portal saw an infant die three days after the 
insertion. 

98. Sir Astley Cooper, some time after the beneficial employment 
of compression already mentioned, attempted, and with perfect suc- 
cess, to cure the disease radically, by evacuating the fluid, and then 
applying pressure. The case is as follows: "Jan. 21, 1809. — Mrs. 
Little, of Limehouse, brought to my house her son, aged ten weeks, 
who was the subject of spina bifida. The tumor was situated on the 
loins ; it was soft, elastic, and transparent, and its size about as large 
as a billiard-ball when cut in half; his legs were perfectly sensible, 
and his urine and feces were under the power of the will, &c. Hav- 
ing endeavored to push the water contained in the tumor into the 
channel of the spine, and finding that if the whole were returned the 
pressure would be too great for the brain, I thought it a fair oppor- 
tunity of trying what would be the effect of evacuating the swelling 
by means of a very fine-pointed instrument, and by subsequent pres- 
sure to bring it into the state of the spina bifida in Applebee's child. 
I therefore immediately punctured the tumor with a needle, and drew 
off about two ounces of water. On the 25th of January, finding the 
tumor as large as before it had been punctured, I opened it again, and 
in the same manner, and discharged about four ounces of fluid. The 
child cried when the fluid was evacuated, but not whilst it was passing 
off. On January 28, the tumor was as large as at first. I opened it 
again, and discharged the fluid. A roller was applied over the tumor 
and around the abdomen. Feb. 1, it was again pricked, and two ounces 
of fluid discharged. On the 9th, the same quantity of fluid was eva- 
cuated as on the 4th, but instead of its being perfectly clear as at 
first, it was now sanious, and had been gradually becoming so in the 
three former operations. On the 13th, the same quantity of fluid 
was taken away, a flannel roller was applied over the tumor and 
around the abdomen ; a piece of pasteboard was placed upon the 
flannel roller over the tumor, and another roller over the pasteboard 
to confine it. On the 17th, three ounces of fluid, of a more limpid 
kind, were discharged; the pasteboard was again applied. On the 
27th, the surface of the tumor inflamed; the fluid, not more than 
half of its former quantity, was mixed with coagulable lymph, and 
the child, suffering considerable constitutional irritation, was ordered 
calomel and scammony, and the rollers were discontinued. On the 
26th, the tumor was not more than a quarter of its former size; it 
felt solid, the integuments were thickened, and it had all the ap- 
pearance of having undergone the adhesive inflammation. On the 
28th, it was still more reduced in size, and felt solid. March 8, the 
swelling was very much lessened, the skin over it thickened and 

1 Traits de Mai. Chirurg., 1779, vol. ii. 

2 Stance pub. de la Soc. Roy. de Paris, Dec. 9, 1779, p. 32. 



INTRA-UTERINE OR CONGENITAL DISEASES. 81 

wrinkled; a roller was again had recourse to; a card was put over 
the tumor, and a second roller applied. March 11, the tumor was 
much reduced; the skin covering it was a little ulcerated. On the 15th 
it was flat, but still a little ulcerated. On the 27th, the effused coagu- 
lable lymph was considerably reduced in quantity, and of a very firm 
consistence. On the 2d of May nothing more than a loose pendulous 
bag of skin remained, and the child appearing to be perfectly well, the 
bandage was soon left olf." 1 No further inconvenience was felt by the 
child, and Mr. S. Cooper had an opportunity of examining both this 
case and the previous one (Appiebee) in January, 1838, Mr. Little 
beirjg then twenty-eight years old, and Mr. Appiebee twenty-nine. 
Both were active and in perfect health. 2 

The operation by puncture has been several times performed since. 
Dr. Sherwood tried it and failed. 3 Otto punctured a tumor in a child also 
affected with hydrocephalus, and the tumor disappeared, but the child 
died three weeks afterwards. 4 Pliny-Hayes lost a patient in two days 
after a single puncture. 5 In 1819, Dr. Berndt failed in three cases; 
the first died twelve days after the operation, the second after three 
weeks, and the third after three punctures. Benedict Trompei per- 
formed the operation upon a girl of six years old, with a cataract needle, 
and she died comatose thirteen days after. I tried the same plan three 
or four years ago, and the tumor was becoming more solid, so that I 
began to have some hope of success, when the child was seized with 
convulsions and died. 

I have also tried puncture with direct and lateral compression with- 
out success. 

Still, small as the chance is, it would appear that, of all the methods 
proposed, the most feasible is compression alone or combined with acu- 
puncturation. 

MM. Robert, Rosetti, and Ptuggretin have successfully used punc- 
ture with compression. 

In the New York Journal of Medicine for September, 1843, a case 
is related by Dr. Stevens, of New York, successfully treated by punc- 
ture alone. The tumor was about three inches and a half broad from 
side to side, and it was punctured three different times, and more than 
nine ounces of fluid escaped. After the last operation the sac inflamed, 
and the child became irritable and restless; -but these symptoms soon 
subsided, and a year after nothing remained of the sac but a small bunch 
of indurated and corrugated integument. The child was eight months old. 

Dr. Nevins mentioned at the Liverpool Pathological Society, three 
cases in Avhich puncture had been tried. One case was cured, the gen- 
tleman being now 40 years of age; the second died, and the third was 
cpuite well at the end of three or four months with the sac contracted. 6 
Dr. Plana, of Illinois, has related a case in which spontaneous rupture 
of the sac took place after measles, and the child recovered (Amer. 
Med. Journal, Oct. 1860, p. 551). 

1 Med. Chir. Trans., vol. ii. p. 326. 2 Surg. Diet., p. 1173. 

3 Med. Repository-, 1S12, vol. i. " 4 Oliivier, Mai. tie la Moelle Ephi., vol. i. p. 20&. 

5 Braithwaite's Retrospect, vol. ix. p. 240. 

6 Lond. Medical Gazette, Jan. 1850. 

6 



CEPHALHEMATOMA. 



CHAPTER II. 

CEPHAL^MATOMA— FRACTURES OF THE CRANIUM, ETC. 

99. The tumors -which are observable on the head of the infant 
at birth, although congenital, are not of intra-uterine growth, being 
entirely mechanical in their origin, and produced during the passage 
of the child into the world. After the liquor amnii has been discharged, 
the head of the child comes into immediate contact with the cervix 
uteri, occupying or closing the partially dilated os uteri, the edges 
of which, according to the resistance they offer, press more or less 
firmly upon the scalp. If this circular pressure be considerable, it 
necessarily interrupts the cutaneous circulation, and after a time the 
portion of scalp thus inclosed is observed to swell, and become more 
or less tense; and if the head of the child be examined after its birth, 
a tumor of varying size and density will be discovered at this part. 
This is what has been called the caput suocedaneum. The size of the 
tumor is in proportion to the delay and pressure at the orifice through 
which the head passes, and its situation indicates accurately the part 
which presented; the primary tumor being formed by the os uteri, and 
a secondary or supplementary one by the vaginal orifice, if there be 
much resistance or delay there. If the part presenting, then, be the 
same as at the os uteri, the tumor will merely be enlarged ; but if the 
position of the head be altered, it will be extended in one direction or 
the other, according to the part embraced by the external orifice. As 
the situation of these swellings is sometimes of importance to their right 
diagnosis, I shall shortly state where we find them in the different posi- 
tions of the head. 

In the first position, the head lies across the brim of the pelvis in its 
left oblique diameter, with the posterior fontanelle towards the left 
acetabulum; the os uteri embraces part of the right tuber parietale 
and the bone superior to it up to the suture, and in this situation we 
find the primary tumor, which, by the pressure of the lower outlet, is 
generally extended posteriorly, whilst it embraces more of the tuber 
parietale. 

In the second position, the tumor is formed in the same situation, but 
upon the left parietal bone, i. e. on the superior, and rather posterior 
part, including more or less of the tuberosity. 

In the third position, I have found the primary tumor more an- 
terior, or nearer to the anterior angle of the left parietal bone, than 
the posterior, but owing to the change from the third to the se- 
cond position, which the head makes in its transit through the cavity, 
the secondary tumor is extended posteriorly over the greater part 



CEPHALHEMATOMA. 83 

of tlie tuber and the superior and posterior part of the parietal 
bone. 

So in the fourth position, the primary tumor is formed anterior to the 
tuber, but at the lower outlet extended posteriorly. 

In the first position of face presentation, viz: with the forehead 
towards the left ilium, "there forms," says Naegel^, 1 "a swelling, first 
upon the upper part of the right half of the face, which in this species 
of face presentation is always situated lowest." " But if the third stage 
advance slowly, the inferior half of the right side of the face, viz : part 
of the right cheek, will be remarked after birth as being the principal 
seat of the swelling." 

In the second position of the face — the forehead towards the right 
ilium — the left side of the face is the seat of the tumor, or of the red 
mark which indicates it ; the upper part of the primary, the lower of the 
secondary tumor. I should mention that the situation of the tumor in 
face presentations is indicated rather by a red-colored mark (the result 
of pressure) than by a defined swelling. 

100. We may now turn to the examination of these tumors them 
selves, their nature, pathology, and treatment, and it will be seen 
that they are by no means so simple or so uniform as might be sup- 
posed. The simpler ones are by far the most frequent, in fact it is 
seldom that we meet with the cephalsematoma, as they are called : I 
have myself for some time past taken every opportunity of examining 
these tumors, and such information as I have been able to obtain 
I shall incorporate with that given by the authors whose works I have 
consulted. 

I. The simplest and most common tumor, when laid open, will 
be found to consist of yellowish serum, effused under the scalp, and 
very rarely also beneath the pericranium. The scalp preserves its 
usual density, and the bone and pericranium are in a state of perfect 
integrity. 

The tumor is formed during the passage of the head of the child, and 
does not increase after birth. It is limited simply by the pressure of 
the os uteri and os externum. For this kind of tumor no treatment is 
necessary, as very shortly after birth it loses its peculiar form, and after 
twenty-four hours often entirely disappears. If not, a spirit lotion, 
occasionally applied, will hasten its dispersion. 

II. Occasionally, instead of simple serum, the tumor consists of sero- 
sanguineous fluid, owing, probably, to the greater amount of pressure, 
or the fragility of the bloodvessels, or to both. In such cases we find 
the scalp unusually vascular, with small ecchymoses on its surfaces, 
especially the inner. In some cases I have also observed small ecchy- 
moses upon the pericranium and the surface of the skull, but the bone 
is perfectly sound. 

Most of these cases also subside without special treatment, or after 
the application of a spirit lotion; but in some rare examples I have 
known inflammation to attack the tumor, followed by ulceration or 

1 Mechanism of Parturition, Trans., pp. 77, 78. 



84 CEPHALHEMATOMA. 

abscess. This will be the more likely if violence of any kind have been 
used. 

If we find inflammation arising, and the spirit lotion ineffectual, 
the best application is a soft, warm poultice, frequently repeated. 
The same treatment will be the best in case of ulceration, at least at 
first, and afterwards some slightly stimulating ointment or lotion. 

If an abscess form, of course the best plan is to evacuate the pus by 
a free incision, followed by poultices. Fortunately these cases are very 
rare. 

III. The third variety of tumor is the sanguineous, or cephalsema- 
toma, as they are called by Naegele and others. The first writer who 
distinctly described these tumors was Michaelis; 1 he was followed by 
Naegele, 2 Zeller, 3 Hoere, 4 Schwarz/ Golis, 6 Osiander, 7 Chelius, 8 Henke, 9 
Rau,'° &c, Moscati and Palletta; 11 and from the facts published by 
these authors, the Memoirs of MM. Pigne 12 and Dubois 13 were written. 
M. Halmagrand, in his edition of Maygrier, 14 and M. Velpeau, ,;S have 
also added observations of their own to the results previously before the 
profession. But by far the best essay I know, and one to which I have 
been largely indebted, is that of M. Valleix, formerly "interne" at the 
Hopital des Enfans Trouve's, in Paris. 16 

The simplest and most general of these tumors, which are essentially 
of the same nature, is, according as the blood is effused immediately 
under the scalp, under the pericranium, or within the skull. Chelius 
and Hoere describe cases where the effusion takes place in the diploe of 
the cranial bones. 



SUB-APONEUROTIC CEPHAL2EMAT0MATA. 

101. This is the simplest but apparently not the most common 
form of sanguineous tumor, as in about 500 new-born children, 
M. Valleix observed it but twice, and neither Naegele nor Zeller allude 
to it. It has been described by Baudelocque, 17 Velpeau, Dubois, &c. 
The blood is effused immediately underneath the cranial integument. 
In most cases it is probably owing to the violence of the labor, and 
sometimes to external violence. In most cases it is promptly dis- 
sipated. 

1 Ueber erne eigene Art von Blutgeschwiilsten, &c. — Loder's Journal, vol. ii. cah. 4. 
1804. 

2 Erfahrungen unci Abhandlungen, &c, p. 247. 1812. 

3 Thesis, Comment, de Cephalaemate. 1822. 

4 De Tumore Cranii rec. nator. sang. 1821. — Siebold's Journal, vol. v. 

5 Siebold's Journal, vol. vii. part 2, p. 440. 

6 Pratische Abhandlungen, &c. "' Handbucli der Entbindungskunst, &c. 
8 Manuel de Chirurg. (Trans.), vol. ii. p 186. 9 Kinderkrankheiten, p. 148. 

10 Handbuch der Kinderkrankheiten, p. 78. 

11 De Abscessu sang, capit. mediol. 1810. 12 Journal Ilebdom. Sept. 1838. 
13 Nouv. Diet, de Medecine, vol. vii. p. 88. M Page 551. 

13 Traite* des Accouch., p. 510. Ed. de Bruxelles. 

16 Mai. des Enfans, p. 495. 

17 Art. des Accouch., part i. oh. ii. sect. 11. 



CEPHAL^IMATOMA. 85 



SUB-PERICRANIAL CEPHALHEMATOMA. 

102. This appears to be the most common form of the sanguineous 
tumor, though after all it is rare. M. Naegele met seventeen cases 
in twenty years' practice, and it is the only kind described by him 
and Zeller. Hoere thinks it tolerably frequent. Palletta found but 
a few cases in a great many children. M. Baron estimates its occur- 
rence at about in 1 in 500 children. 1 M. Dubois, during a number of 
years at La Maternite" (where from 2500 to 3000 children are born an- 
nually), has seen but six cases. Dr. Doepp, of St. Petersburg, states, 
that in the Foundling Hospital it occurred in 262 cases in eleven years, 
or in one in 190 of the whole number of children in the hospital. M. 
Velpeau refers to five cases, and M. Valleix 2 met with four cases in 
1987 children in five months at the Hopital des Enfans Trouves, or 
about one in 887. 

According to most writers, the tumor is seated about the posterior 
and superior angle of the right parietal bone, or nearly in the situa- 
tion of the tumor in the first position; and when small it is placed 
above, and distinct from the tuber parietale. It is occasionally, but 
rarely, met with on the left parietal bone, and still more rarely in any 
other situation. Ordinarily there is but one, but sometimes we- may 
observe one on each parietal bone, separated by the sagittal suture. 
Naegel£ has, however, mentioned a case where a greater number were 
found. Of six cases seen by M. Valleix, three were on the right parietal 
bone, two on the left, and in one there was a tumor on each bone, but 
which, he states distinctly, was not the result of the blood passing across 
the suture. 

I have, however, seen one remarkable case in which, after a short and 
easy labor, a tumor formed on each tuber parietale, and on being punc- 
tured, a small quantity of thick dark blood escaped, and then the scalp 
assumed its natural condition. I am quite at a loss how to explain the 
production of the double tumor. The second stage was completed in 
ten minutes, and it was the patient's seventh child. 

The size of -these tumors varies from that of a small nut to a 
swelling occupying the whole parietal bone. In the case of double 
tumor, related by Mr. Valleix, they were the size of an apricot 
kernel ; in two others they covered seven-eighths of the parietal 
bone. 

There is no proof of these tumors existing before the completion 
of labor; if we make an examination some hours, or a day, after 
birth, we find a small tumor, slightly tense, fluctuating, and on 
pressure from the edge of the tumor inwards we can feel the bone 
entire. In rare cases the integuments are of a deep red color, and 
slightly cedematous; 3 and still more rare is it to find a pulsation in 
the tumor, although jSTaegel& states that he did so in two or three 
instances. 

1 Diet, de M&l., Art. Cepbalsematome. 2 Mai. des Enfans, p. 500. 

3 Valleix, Mai. dew Enfans, p. 5U2. 



86 CEPHALHEMATOMA. 

But the most striking peculiarity of this variety is a bony circle — 
"cercle osseux, bourrelet osseux" — which is formed around the ef- 
fused blood, and limiting it. Palletta has mistaken this for the edge 
of an opening through the cranium, and to this cause he attri- 
butes the formation of the tumors. However the bone, as Valleix 
remarks, can be distinctly felt uninjured within this bony ridge, if 
we pass the finger from the outer edge inwards to the centre. 1 Mi- 
chaelis states that the bony circle may be felt from the commence- 
ment of the tumor; but in this he is not borne out by the researches 
of Naegel^, Zeller, Hoere, and others, who examined with great care. 
M. Valleix says, that in two cases which he saw only at an early 
period, he could not detect it: in one it had just commenced, and in 
a fourth it had not at first attained its full development, but it did 
afterwards. Wigand relates two cases in which no circle could be felt 
until twenty-four hours after birth; and M. Fortin, 2 one in which no 
circle was present immediately after birth, but which was formed 
within two days. From these facts we may conclude that it is not 
present at the commencement of the formation of the tumor, but that 
it is a subsequent production. It is very perceptible to the touch 
when found, surrounding the tumor entirely, except when it is over the 
sutures. 

The tumor rapidly acquires its full development, sometimes in a few 
hours, sometimes in a day or two, and at each time we find it of different 
sizes in different cases, tense, rounded, defined, elastic, and with fluctu- 
ation almost always perceptible. Generally speaking, the color of 
the skin is unchanged, and it is neither ecchymosed nor cedematous, 
though there are exceptions. No alteration of the volume is produced 
by pressure made upon the tumor, nor does it cause stupor, coma, or 
convulsions; and, according to Valleix, it is quite consistent with the 
health and thriving condition of the child. Palletta states that the size 
of the tumor continues to increase until it is opened, but this is not the 
case : it may increase until the bony circle is formed, but this appears 
to determine its extent. 

Diagnosis. — These sanguineous tumors have been mistaken for 
hernia cerebri, and perhaps this is the disease with which they are most 
likely to be confounded. MM. Ledran and Corvin made this mistake, 
as was subsequently pointed out by M. Ferrand. 3 And yet the differ- 
ential symptoms are sufficiently marked, for in cephalgematomata there 
is always fluctuation, which is not present in hernia cerebri: in the 
latter there is always pulsation, but never in fully-formed cephalsema- 
tomata, and very rarely indeed even at the beginning. In hernia cerebri 
the perforation in the skull may always be felt, whereas in cephalaema- 
tomata by a little care we can always (with only one or two exceptions 
on record) feel the cranium beneath the tumor. In hernia, compression 
gives rise to symptoms of cerebral pressure, but not with cephal?emato- 
mata ; and lastly, cephalsematomata almost never form upon the sutures, 
whereas this is the most frequent seat of hernia cerebri. In a case 

1 Valleix, Gaussail.— Presse Med., 1837, No. 54. 

2 Cephal. sous-pericran. — Ibid., No. 39. 3 Mem. de l'Acad. de Chir., vol. v. p. 47. 



CEPHALHEMATOMA. 87 

related by Fried, hernia cerebri occupied the occiput, and a sanguineous 
tumor each parietal bone. 1 

As Dubois observes, there is no danger of confounding cephalsema- 
tomata with hydrocephalus externus, and the osseous circle will distin- 
guish them from the aqueous cysts mentioned by Zeller. Hcere mentions 
in his Memoirs a case of fungus of the dura mater, but this disease is 
so rare in infancy (if it ever occur at so early a period) that we run 
little risk of mistaking the one for the other. 

Valleix relates a case of abscess of the scalp circumscribed by a 
thickened condition of the cellular membrane, which had considerable 
resemblance to the osseous circle, but the previous history differed con- 
siderably ; for abscess is not formed so soon after birth, makes slower 
progress, is irritable and painful, and the condensed cellular membrane 
does not form so hard a boundary as bone. 

The ordinary caput succedaneum is softer, pitting on pressure, but 
not fluctuating, not so defined, without the bony circle, and is speedily 
dissipated. The sub-aponeurotic cephalsematomata are more rapidly 
formed, the skin is discolored, the tumor is sometimes painful, but not 
circumscribed, and without the bony circle. M. Dubois saw in the 
same child the sero-sanguineous tumor, the sub-aponeurotic, and the 
sub-pericranial cephaloematomata, the coexistence of which would, of 
course, embarrass the diagnosis. 



SUBCRANIAL CEPHALHEMATOMA. 

103. This variety is extremely rare. Hoere was the first to describe 
it, 2 and since then MM. Moreau and Dubois 3 have detailed each a case. 
M. Baron states that he has seen several; 4 and M. Padieu showed to 
M. Valleix the parietal bone of an infant, which had been the seat of 
one. 5 M. Valleix has found the dura mater separated by effused blood, 
but which was not limited so as to form a tumor. 

The blood is stated by Chelius and others to be effused into the diploe 
of the cranial bones ; by others, on the external or internal surface of 
the dura mater. 

My friend, Dr. West, of London, has lately published a very inte- 
resting case of external and internal cephaljematoma, with fracture of 
the frontal bone. The child died twenty-three or twenty-four days 
after birth, of convulsions. The tumor was about the size of a walnut 
originally, but it extended so as nearly to cover the right parietal bone. 
On dissection the tumor was found filled with coagulated blood, under- 
neath which was " a semicircular layer of dense, reddish, fibrinous exu- 
dation, about three lines broad, wedge-shaped, with its narrow edge 
directed inwards." The subjacent surface of the bone was rough and 
uneven. The right parietal bone was then removed, but previously a 
fissure, with clean edges, was noticed in the bone, running from the 
coronal suture obliquely backwards and upwards. " On the inner sur- 

1 Extract, de Thesis de Haller, vol. i. p. 110. 2 De Tumore Cranii, &c. 

3 Diet, de Med., Art. Cephakematome. i Ibid. 

5 Mai. des Enfans, p. 512. 



88 CEPHALHEMATOMA. 

face of the bone was an effusion of blood between the cranium and the 
dura mater, more than half an inch in thickness, and occupying the 
whole of the fossa of the parietal bone." "Between the two layers of 
the dura mater by which it was covered, were numerous bony deposits, 
and a ring of newly formed bone surrounded its base." 1 

Dr. West thinks, and I believe correctly, that the fracture occurred 
during labor, although it was quite natural and easy. Such occurrences 
have been noticed by D'Outrepont, Carus, Hoere, and Danyau. They 
are still more likely, and more easily explained, when the pelvis is nar- 
rowed by undue projection of the sacral promontory, as in Monde's, 
Adelmann's, and Becher's cases. 

104. Pathology. — In describing the appearances in sub-pericranial 
cephalhematoma, discoverable in dissection, I shall give the substance 
of M. Valleix's researches, which are by far the most minute and 
accurate of any. 

The scalp has generally its natural aspect, although Osiander and 
others speak of its being red or livid. "Its substance is always unin- 
jured. The pericranium preserves its transparency, and through it is 
perceptible the deep color of the effused blood. M. Dieffenbach 2 has 
noticed a thickening of the pericranium, which is confirmed by M. Val- 
leix. At the circumference of the tumor the pericranium is adherent 
to the bony circle, but it is never ossified itself, according to M. Val- 
leix, although Chelius has found it so. According to M. Valleix, the 
effused blood is enveloped in a sac formed of a fine membrane, having 
all the characters of condensed cellular tissue, around which he observed 
an adventitious tissue, consisting of a cartilaginous plate, varying from 
a line to half an inch in breadth, and about half a line in thickness, 
gradually thinning externally. It is placed on the bone, from which it 
is easily detached, and underneath the pericranium, to which it adheres 
more firmly, but from which it can be detached, leaving the membrane 
in its natural state. In the under surface of the cartilaginous plate, 
points of ossification may be observed. 

The state of the bone underneath the tumor has been differently 
described by different authors. Michaelis and Palletta, who attribute 
the affection to disease of the bones, think that the outer table of the 
bone is necrosed, carious, and destroyed, and that the injured vessels 
of the diploe give rise to the hemorrhage. Naegele, Zeller, Hoere, 
Valleix, and others, differ from this view, and this opinion is founded 
upon examinations made after incisions have been practised and after 
death. Valleix found part of the surface smooth, but sprinkled with 
numerous irregular osseous rugosities, very difficult to be detached, but 
neither carious nor destructive. 

The bony circle always surrounds the tumor entirely, except when 
it is seated near to the suture : it consists of a bony ridge placed upon 
the bone, from which it may easily be detached, exposing the parietal 
bone unaltered. It appears of different degrees of consistence, accord- 
ing as the process of ossification is more or less advanced. Its height 

1 Transactions of Med.-Chir. Soc, vol. xxyiii. 

2 Abscessus Capitis Sang. Neonat. — Rust's Magazin, 1830. 



CEPHALHEMATOMA. 89 

varies in different cases, and in different parts of the circle, varying 
from half a line to a line and a half. 

105. Terminations. — Velpeau gives the following statement from 
Naegele as the process of cure : — 

"i. The detached pericranium becomes ossified on its internal sur- 
face. 

"ir. In proportion as the effused blood is absorbed, the ossified peri- 
cranium approaches the cranium, and at length is united to it. 

"in. After six months, or even a year, we may still remark an ele- 
vation at the place where the tumor was situated. 

"iv. In children who died six months or a year after, M. Naegele 
found, on making a section of the parietal bone, that it was much 
thicker at the situation of the tumor." 1 M. Valleix states, that in one 
case the bony circle gradual^ increased internally, until it nearly 
occupied the whole extent of the tumor, and that the fluid disappeared 
in the same degree. 

The tumors, if untouched, are rarely cured within forty days ; they 
may, however, disappear, though not often without opening, and in the 
majority of cases there is no danger. 

106. Treatment. — I have already stated that for the simpler forms 
nothing beyond cold lotions or spirit wash will be necessary, unless 
ulceration take place, or an abscess form. The same treatment may 
be tried in the subaponeurotic cephalhematoma, and will generally suc- 
ceed. Even the sub-pericranial tumors may be dissipated, according 
to Gb'lis, Rau, Halmagrand, and others, when slight. The latter author 
speaks highly of a lotion of the hydrochlorate of ammonia in red wine. 
Others recommend the usual cold and spirituous lotions. Henschel 
recommends pressure. 

If these means fail, and they will fail if the tumor be large, it will 
be necessary to make an opening into it. For this purpose Moscati 
and Palletta passed a seton through the tumor to provoke suppuration, 
on the supposition that the bone was diseased. Gb'lis of Vienna esta- 
blishes a slight issue on the top by means of caustic potash, in hopes of 
promoting absorption ; and he cites thirty-two cases of cure by this 
means, in from fourteen to eighteen days ; but Zeller throws great 
doubt upon some of these ; Krukenberg and Schmitt, however, adopt 
Gb'lis's plan. Lbwenhardt recommends puncture with a trocar, and 
strapping. By far the simplest mode, however, is to make an incision 
with a bistoury, sufficiently ample to evacuate the contents of the tumor; 
and by most writers this plan is preferred. The wound may be dressed 
with charpie, according to Chelius, or with spermaceti cerate ; or, when 
the blood is evacuated, a strap of plaster may be passed across it. The 
simpler the dressing the better. I may remark, in conclusion, that we 
should take care not to make the incision near any of the principal 
arteries of the scalp. 

107. I give the following notice by Dr. Schbller, of Berlin, of a 
case of injury arising from pressure, although it does not properly 
belong to any of the varieties of swelling on the scalp just described, 

1 Art. des Accoucbemens, p. 512. 



90 IRRITATION OF THE NERVOUS SYSTEM. 

on account of its rarity and interest. "A healthy young woman was 
seized with labor of her first child, August 23, 1839. The first stage 
was very tedious, and the pelvis very small. At the end of three days, 
and after the use of venesection and opium, she was delivered of a small 
child. Its head was a quarter of an inch smaller than usual in each 
diameter ; a large caput succedaneum occupied the right parietal bone ; 
and in the middle of the left parietal, and -in the neighborhood of the 
left temple, the skin was abraded and the bone depressed. The skin 
about these parts became gangrenous, and a red line of demarcation 
surrounded the mortified structures. The bone beneath likewise died, 
and a portion as large as a sixpence of the whole thickness of the 
parietal bone exfoliated, leaving the dura mater exposed. The destruc- 
tion of the frontal bone Avas less considerable, and was replaced by 
granulations which, on September 13, had likewise advanced so far 
towards restoring the lost part of the parietal bone that the child was 
dismissed from hospital." 1 A similar case is recorded by Meine in his 
thesis Be Osteomalacia et ejus in partum actione. 



CHAPTER III. 

IRRITATION OF THE NERVOUS SYSTEM. — TRISMUS NASCENTIUM. 



NERVOUS IRRITATION. 

108. When we consider the delicate structure of the brain in infants, 
the great vascular action going on therein, the influence reflected 
upon it from the different organs, and the stimulation to which it is 
exposed from external impressions (22), we cannot be surprised that 
it should be liable to various degrees of disturbance, from simple irri- 
tation up to disorganization. Some of these attacks are apparently 
merely functional, i. e. they entail no permanent disorder and leave 
no pathological traces in the structure of the organ, so far as we can 
ascertain. They do not amount to inflammation, but consist probably 
in temporary irritation, with probably some degree of congestion 
or unequal circulation. Without attempting to explain further what 
we confessedly do not as yet understand, I shall proceed to notice the 
ordinary forms of nervous irritation occurring in infants and young- 
children. 

109. In very mild cases the principal symptoms are great wakeful- 
ness and a keen sensibility to slight impressions, much restlessness, and 
rather more animation than usual. In severer cases these symptoms 
are aggravated; the infant sleeps very little, and is awoke by the 

1 Medicinische Zeitung, September 22, 1841. 



IRRITATION OF THE NERVOUS SYSTEM. 91 

slightest movement; is painfully sensitive to sound and light: the 
temper becomes irritable, and it is scarcely possible to please the child; 
it cries on the slightest occasion, and is only soothed -when at the breast. 
It is restless, keeping the limbs in constant motion, and requiring the 
nurse to walk about with it constantly. Its sleep is not the calm rest 
of a healthy infant ; it starts now and then, a frown passes over its 
forehead, the eyelids are occasionally squeezed together, and the least 
noise disturbs it. The arms are tossed about, and the lower limbs fre- 
quently moved. 

The bowels in some cases are regular, but more frequently they 
are deranged, either confined or relaxed, or the motions exhibit an 
unhealthy character. The pulse is quicker than natural, and the heat 
of the surface increased. So far these symptoms resemble very closely 
those which usher in convulsions, neither can we be sure that any 
case in which they are present may not thus terminate, although, if 
promptly and judiciously treated, the attack may generally be ar- 
rested. 

110. But nervous irritation may show itself in another form, and with 
somewhat opposite characters. The infant is heavy and dull, yet fretful 
when disturbed or touched; it is uneasy except when resting the head 
on the nurse's arm or on its pillow; it does not sleep, and yet is scarcely 
awake; there is a great indisposition to move or make any exertion, with 
an indifference to all objects. The eyes are dull and frequently roll- 
ing or turning upward with an occasional wide stare ; the child is rest- 
less, tossing its arms, and moving its legs about uneasily; starting in 
its sleep, and awaking crying, or as if frightened. There is a general 
pallor and chilliness of the body; the face is of a dull lead color and 
darker underneath the eyes. The heat of the head may be natural, or 
slightly increased. 

If its course be not arrested, this form of irritation of the nervous 
system may run on into convulsions ; for this very reason, it would ap- 
pear, writers have generally omitted to notice these attacks, regarding 
them, doubtless, as the first stage of convulsions; but I have seen them 
so frequently stopping short of that extreme, either spontaneously or 
under the influence of treatment, that I felt it right to allude to them 
separately. Dr. Whitlock Nicholl has published a monograph 1 on the 
subject, containing much valuable matter, which the reader would do 
well to consult. 

111. The late Dr. Gooch has described, 2 with his usual discrimi- 
nation, a class of cases in which the "symptoms are erroneously 
attributed to congestion of the brain," and which closely resemble 
the last form of nervous irritation. "It is chiefly indicated by hea- 
viness of head and drowsiness. The age of the little patients whom I 
have seen in this state has been from a few months to two or three 
years ; they have been rather small of their age, and of delicate 
health, or they have been exposed to debilitating causes. The physi- 

1 Practical Remarks on disordered States of the cerebral Structures, occurring ia 
Infants, p. 10. 1821. 

2 Diseases of Woman, p. 357. 



92 IRRITATION OP THE NERVOUS SYSTEM. 

cian finds the child lying on its nurse's lap, unable or unwilling to raise 
its head, half asleep, one moment opening its eyes, and the next closing 
them again, with a remarkable expression of languor. Its tongue is 
slightly white, the skin is not hot ; at times the nurse remarks that it is 
colder than natural; in some cases there is at times a slight and tran- 
sient flush ; the bowels I have always seen already disturbed by purga- 
tives, so that I can scarcely say what they are when left to themselves: 
thus the state which I am describing is marked by heaviness of head and 
drowsiness, without any signs of pain, great languor, and a total absence 
of all active febrile symptoms. The cases which I have seen have been 
invariably attributed to congestion of the brain, and the remedies em- 
ployed have been leeches and cold lotions to the head, and purgatives, 
especially calomel. Under this treatment they have gradually become 
worse, the languor has increased, the deficiency of heat has become 
greater and more permanent, the pulse quicker and weaker, and at the 
end of a few days or a week, or sometimes longer, the little patients 
have died with symptoms apparently of exhaustion. In two cases, 
however, I have seen, during the last few hours, symptoms of oppressed 
brain, as coma, stertorous breathing, and dilated, motionless pupil." Dr. 
Marshall Hall has also described a similar form of disease, attributing 
it to the same causes. Dr. Abercrombie remarks: "I have many times 
seen children lie for a day or two in this kind of stupor, and recover 
under the use of wine and nourishment. It is scarcely to be distin- 
guished from the coma which accompanies diseases of the brain. It 
attacks them after some continuance of exhausting diseases, such as a 
tedious and neglected diarrhoea; and the patients lie in a state of insen- 
sibility, the pupils dilated, the eyes open and insensible, the face pale, 
and the pulse feeble. It may continue for a day or two, and terminate 
favorably, or it may be fatal." 1 

Dr. Whitney, in a valuable paper on cerebral auscultation, mentions 
that in such cases he has detected a bellows-sound in the arteries of 
the head, with a rasping, chirping sound occasionally ; and he regards 
these sounds, in combination with the anaemic condition of the patient, 
as characteristic of the disease. 2 

I have not been equally successful in hearing these sounds, nor in 
deciding upon the value of cerebral auscultation. Perhaps further 
investigation may throw some light upon the subject. 

Now, as an organ may be in a state of irritation from a deficient as 
well as from an excessive supply of blood, either error destroying its 
healthy equilibrium, I do not know a better term by which to indicate 
both conditions than nervous irritation ; but, whatever nomenclature 
we use, they are to be observed in practice, and are of considerable 
mportance. 

112. Causes. — In the first variety, I think, there will generally be 
found some disorder of the stomach or bowels, or both. The child may 
have been eating some indigestible food, or, without any special cause, 

1 Diseases of the Brain, p. 810. 

3 American Journ. of Med. Science, Oct. 18-13, p. 318. 



IRRITATION OF THE NERVOUS SYSTEM. 93 

the mucous membrane of the stomach and bowels has become deranged, 
and there is occasional vomiting, or purging, not of large but of small 
and frequent stools, with great flatulence. 

In some cases, no exciting cause can be detected; but the attack 
seems to be the commencement of some serious affection of the nervous 
system, presenting the character and symptoms I have described, and 
either subsiding spontaneously or from judicious treatment, or really 
developing itself in a graver form, or lastly, as it were, projecting itself 
upon some other organ, and giving rise, e. g., to spasm of the glottis. 

In the second variety, where torpor is the characteristic symptom, 
the cause seems to be a feeble state of constitution, and exhaustion 
from some other disease, as diarrhoea, increased by treatment of the 
primary affection, or that which has been erroneously directed to the 
cure of supposed cerebral disease. 

113. Treatment. — In the first variety, if the pulse be quick and firm, 
and there be any heat of the scalp, I have found immediate and great 
relief from the loss of a small quantity of blood by leeches. And as 
this is the first time I have had occasion to mention leeches, let me 
recommend to my readers that, in all cases ivhere they are applied to 
infants or children, the bleeding should be arrested at once when they 
fall off. By so doing, we can estimate exactly the amount of blood 
lost, and we avoid the great mischief of continued draining. Of course, 
it will be necessary to apply a greater number of leeches than usual, 
or to repeat them; but that is of no consequence compared with the 
danger of the ordinary method. Each leech will abstract from one to 
two drachms of blood, and the number must be proportioned to the 
amount we wish to take away; and, in the following pages, when speak- 
ing of the number of leeches to be applied, I must request the reader 
to bear this in mind, and that I do not include any subsequent draining 
from the leech-bites. 

After leeching, or, if that be unnecessary, sponging the head with 
cold water, or a cold lotion, and a warm foot-bath at bedtime, will 
calm and soothe the infant, and perhaps procure for it some refreshing 
sleep. 

The state of the stomach and bowels demands immediate attention. 
If they are too free, as well as disordered in the character of the eva- 
cuations, it is better first to quiet the excessive action before attempting 
to correct the secretions ; and I have found for this purpose the follow- 
ing simple mixture of great use. The proportions are, for a child of 
twelve or fourteen months old, 

R — .Mucilag. acaciae, 
Syr. zingib., aa gij. 
Tinct. opii, gutt. j to iij. 
Aquas carui \el anisi 5J. — M. 

A teaspoonful may be given every three or four hours until the bowels 
are quieter, and then at longer intervals; or we may substitute tincture 
of hyosciamus for the laudanum. When the bowels are steady, the mer- 
cury with chalk, with the addition, if necessary, of a little compound 
powder of chalk, may be given; or, instead of the gray powder, minute 



94 TRISMUS NASCENTIUM. 

doses of calomel — say one-sixth of a grain. The diet should consist of 
milk, thin arrowroot, panada, &c, without stimulants ; hut, when the 
irritation subsides, a little broth may be given. 

In some cases, I have seen great benefit result from a small blister 
applied for an hour or two behind the ears, across the forehead, or at 
the nape of the neck. 

114. For the second variety, neither depletion nor any exhausting 
remedies are admissible; on the contrary, it is absolutely necessary to 
administer good although bland nourishment. Chicken broth, nicely 
made beef-tea, or beef-gravy, must be given frequently, but in small 
quantities ; and, after a time, a little wine whey or wine and water. 
Ammonia, ether, bark, or some other tonic, will generally be found 
useful. If the bowels are irritable, some soothing medicines must be 
given ; and the head may be sponged with cold lotion, if it be hot, or a 
foot-bath used. 



TRISMUS NASCENTIUM. — NINE-DAY FITS. 

115. This disease, which consists in intense cerebro-spinal irritation, 
seems peculiar to hot climates, to certain localities in more temperate 
climates, and to vitiated atmospheres. It is frequent in Jamaica and 
the West Indies, according to Dr. Evans and James Clarke, 3 in Cay- 
enne, Minorca, and some parts of Germany. Dr. Schneider was called 
to six cases within fourteen days, in March, 1802, in the town (Fulda) 
in which he resides ; and he states that a midwife of the same place met 
with more than sixty cases in nine years. 2 The town is situated close 
to the river, and very damp ; so far bearing out the truth of Mr. Sau- 
vage's observation, " hie morbus hieme, et cum aura humida advenit 
qua.ui sicca asstate." 3 It only occurred once in the British Lying-in 
Hospital in many years ; 4 and Capuron mentions that he once met it in 
Paris. 5 M. Maturzinski has recorded that, in the Hospital of Stutt- 
gard, from 1828 to 1835, among 848 children, there were 25 cases of 
trismus, or about 1 in 34. 9 In a letter to the editors of the Netv 
Orleans Medical and Surgical Journal for May, 1846, Dr. Wooton 
states that it is of fearful frequency in the cotton plantations in Ala- 
bama. He believes that it destroys more negroes than any other 
disease, always proving fatal ; but he has never seen a white child 
attacked. 7 In private practice, it is rarely met with, even amongst the 
poor ; so that, of the writers who have noticed the disease, very few 
seem to have seen an example of it. 

No institution, so far as I know, has ever afforded such ample ex- 
perience of the disease as the Dublin Lying-in Hospital, before the 
improvements in ventilation and cleanliness, introduced by the late 

1 On the Yellow Fever, 1797. 

2 Edinburgh Medical and Surgical Journal, vol. vii. p. 225. 

3 Nosolog. Method., vol. i. p. 531. 

4 Underwood on Diseases of Children, p. 280. 5 Vol. iii. p. 454. 

6 Gaz. Med., 1837, p. 338. 

7 Transactions of the College of Physicians of Philadelphia, 1847, p. 115. 



TRISMUS NASCENTIUM. 95 

Dr. Joseph Clarke, to whom we are indebted for the best description of 
the attack. 

116. He states that those children who were observed to whine and 
cry very much from their birth, or who started much in their sleep, 
were more liable to the disease. Twisting of the limbs without cause 
when awake, a livid circle about the eyes, sudden changes of color, 
screwing up the lips like a purse, involuntary smiling, with a peculiar 
kind of screech, were certain and not distant precursors. Previous to, 
or along with these symptoms, the infants were greedy for the breast or 
for food, the bowels were easily moved, and the evacuations were some- 
times natural, at others greenish, slimy, or knotty. 

" Generally with one or more of these symptoms preceding, but 
sometimes without any warning whatever, the infants are seized with 
violent irregular contractions and relaxations of their muscular frame, 
but particularly those of the extremities and face. These convulsive 
motions recur at uncertain intervals, and produce various effects. In 
some the agitation is very great ; the mouth foams, the thumbs are 
riveted into the palms of the hands ; the jaws are locked from the com- 
mencement, so as to prevent the action of sucking and swallowing ; and 
any attempts to wet the mouth or fauces, or to administer medicines, 
seem to aggravate the spasms very much ; the face becomes turgid and 
of a livid hue, as do most other parts of the body. From this circum- 
stance, and from the shorter duration of the disease, when it occurs in 
this form, the nurses reckon this a different species, and call it the ' black 
fits.' The conflict in such cases lasts from about eight to thirty hours, 
and in some very rare cases to about forty hours, when the powers of 
nature sink, exhausted and overpowered, as it were, with their own 
exertions." 1 

There is a milder variety, to which the nurses give the name of "white 
fits," in which the convulsive movements of the extremities are less 
violent, the paroxysms less frequent, and the power of sucking and 
swallowing, although enfeebled, is not lost until near death. The attack 
is also more prolonged, lasting from three to nine days. The face 
remains pale, and the body is greatly emaciated. 

Both forms of the disease certainly attack the infant within nine 
days, and generally about the period when the remains of the umbilical 
cord fall off; and both are distinguished from other varieties of con- 
vulsions by the permanent difficulty or impossibility of swallowing, 
hence the more appropriate name of Trismus Nascentium (rather than 
the popular one of nine-day fits) ; for the attack, as Mr. Colles has 
truly observed, resembles very closely tetanus in the adult. He and 
others have also remarked, that plump, healthy-looking children are as 
liable to the attack, as the delicate and weakly. 

117. Causes. — M. Bajon attributes the prevalence of Trismus on the 
coast of Cayenne to cold and the sea wind, as it is unknown in the 
interior ; Dr. Evans to costiveness ; Dr. Bartram to improper swathing 
and the application of scorched linen to the navel ; Dr. James Clarke 
to the smoky, un ventilated state of the huts of the negroes in Jamaica ; 

1 Transactions of the Royal Irish Academy, vol. iii. p. 92. 



96 TRISMUS NASCENTIUM. 

Dr. Underwood to impure air. Dr. Joseph Clarke enumerates three 
especial exciting causes of the disease : first, impure air ; second, neg- 
lect of keeping the infants clean and dry; and third, irregularity of 
living on the part of the mothers, especially the abuse of spirituous 
liquors. But it is to the first of these that Dr. Clarke chiefly attributes 
it, because of its frequency in hospitals, and infrequency among the 
poor who are delivered at their own homes, where want of cleanliness 
and irregularity are more remarkable than in any hospital. At the 
end of the year 1782, of 17,650 infants born alive in the Lying-in 
Hospital, 2944 had died within the first fortnight, or nearly every sixth 
child, and that mainly of trismus. After the precautions he adopted 
to secure pure air and adequate ventilation in the hospital, out of 
3083 born alive only 419 died in the hospital, or one in 19J. And Dr. 
Collins states, that out of 131,227 children born alive only 5500 have 
died, 1 a very striking evidence of the correctness of Dr. Clarke's 
opinion of the value of his preventive treatment. During Dr. Collins's 
mastership there only occurred thirty-seven cases of trismus out of 
16,654 infants born. 

118. Pathology. — It is much easier to determine the predisposing 
and exciting than the proximate causes. Different opinions have been 
held by different practitioners of high estimation as the following sum- 
mary will show. The late Professor Colles attributed trismus to inflam- 
mation and ulceration of the umbilicus, without, however, denying that 
it may be connected with a vitiated state of the atmosphere ; and he 
grounded his opinion upon repeated dissections: "Five years ago," he 
observes, " I first made a careful dissection of the umbilicus of a child 
who had died of locked-jaw, and I have every year since dissected from 
three to six subjects who have fallen victims to this disease." 2 From 
fifteen to thirty post-mortem examinations constitute evidence very well 
worthy of attention ; I shall, therefore, extract his account of the 
appearances observed : " The skin forming the edges of the umbilical 
fossa was in some a little more raised than usual. When the borders 
of this hollow were expanded by introducing a pair of dissecting for- 
ceps, we observed the floor of this cavity not flat, but considerably 
raised in the centre by a knob or large papilla ; both the central raised 
part and the surrounding flat parts of this surface, presented all the 
characters of those new membranes which are formed by suppurative 
inflammation. In some few instances, the fundus of this cavity pre- 
sented evident marks of superficial ulceration, confined to the vicinity 
of the umbilical vein. A probe readily passed through the substance 
of the central tubercle, and entered into the umbilical vein. On cutting 
into the abdomen the peritoneum covering the umbilical vein was highly 
vascular, as if from inflammation ; this extended sometimes up to the 
fissure of the liver, often, however, not for a greater length than one 
inch above the umbilicus. The peritoneum in the course of the umbili- 
cal arteries appeared to be still more inflamed, an appearance which 
extended often as far as the sides of the bladder. Besides the appear- 
ance of the peritoneum along their posterior surface, the cellular sub- 

1 Practical Treatise on Midwifery, p. 514. 2 Dublin Hospital Reports, vol. i. p. 286. 



TRISMUS NASCENTIUM. 97 

stance which covered them and the urachus anteriorly, was loaded with 
a yellow watery fluid, even down to the bladder. Leaving the umbilicus 
untouched, if we cut open the umbilical vein from the liver to the 
vicinity of the umbilicus, we found only a few small coagula within its 
canal; the inner surface of the vein was pale, and free from any marks 
of inflammation, yet the coats of the vein altogether were very much 
thickened. The umbilical arteries exhibited evident marks of inflamma- 
tion : first, on slitting them up, a thick, yellow fluid, resembling coagu- 
lable lymph, was found within their coats ; second, in all cases their 
coats were much thickened and hardened, even as far as the fundus of 
the bladder. On cutting into the umbilicus itself, from its posterior or 
peritoneal surface, we found in the centre a space about half an inch 
long, occupied by a soft yellow substance, which bore a very strong 
resemblance to coagulable lymph produced by inflammation; it was this 
which formed the prominence observed in the external vein of the fossa. 
The extent of this middle space varied in different cases, but in every 
instance the arteries opened into it, or rather were lost upon it. The 
extremity of the umbilical vein was affected in different degrees in 
various instances. In some it presented a pouch or varix, which extended 
one-eighth of an inch below the extremity of the opening of the vein, 
i. e., in a direction towards the opening of the bladder. In some the 
extremity of the vein presented an appearance of ulceration on its 
margins; and all the edges of the extremity of the veins were thickened. 
In every instance the ends of all these vessels remained open ; their 
canals were in continuity with the soft substance which occupied the 
centre of the umbilical space, so that a bristle or small probe passed 
without opposition from their vessels into the soft substance." 1 

In the year 1819, Dr. Labatt, then Master of the Lying-in Hospital, 
published a paper 2 to refute Mr. Colle's views, in which he gives memo- 
randa of nine dissections of infants, six of whom died of trismus, two 
of diarrhoea, and one of an affection of the chest. The peculiarities 
mentioned by Mr. Colles as characteristic of the navel in trismus he 
states to have been absent in all the cases of locked jaw, and many of 
them present in the other cases, so that in the former the umbilicus 
appeared to be perfectly free from disease. 

Dr. Breen, in a valuable paper published some time afterwards, 3 coin- 
cides in a great measure with Dr. Labatt; and Dr. Collins observes, 
that " from dissection we have never been able to discover any morbid 
appearances which would justify us in offering any explanation of the 
pathology of this disease." 4 

It is an old opinion, however, that the disease is in some way con- 
nected with the condition of the umbilical cord. Mosohion thought 
that stagnation of blood in the funis might give rise to serious disease ; 
with which Levret agreed ; and M. Bajon expressly attributes trismus 
to this cause, and advises that the blood should be carefully emptied 
out. Alphonse Le Roi fancied that it might be caused among the 
negro children by the use of dirty, rusty scissors for dividing the cord. 5 

1 Loco citato, p. 286. 2 Edinb. Med and Surg. Journal, vol. xv. p. 216. 

3 Dublin Journal, vol. viii. p. 548. 4 Practical Midwifery, p. 516. 
s Gardien, Traite des Accouch., vol. iv. p. 244. 

7 



98 TRISMUS NASCENTIUM. 

Dr. Wooten made careful investigations on this point, but could come 
to no definite conclusions. The pathological phenomena he observed 
were general peritonitis, and the portion surrounding the entrance of 
the navel-string in a gangrenous condition ; liver engorged ; and heavy 
engorgement of the membranes of the base of the brain, and along the 
medulla oblongata and cervical portion of the "spinal cord. 

119. M. Ollivier, in his excellent work on diseases of the spinal 
marrow, states that he has no doubt that trismus is in many cases iden- 
tical with tetanus from hemorrhage into the spinal canal; and he refers 
to a case of Dr. Abercrombie's, of an infant six days old, who presented 
symptoms resembling trismus, of which he died on the fourth day; and 
on dissection, " in the spinal canal there was found a long, and very 
firm coagulum of blood lying between the bones and membranes of the 
cord on the posterior part, extending the whole length of the cervical 
portion." 1 

Dr. Evory Kennedy has contributed another case, 2 and Professor 
Doherty two cases, in which sanguineous effusion was found to a con- 
siderable extent in the spinal canal, and especially into the cellular 
tissue surrounding the dura mater. 3 

M. Billard, without pronouncing a positive opinion, mentions that 
he had seen but two cases of this disease, and that in both the only 
pathological condition was an effusion of blood into the spinal arach- 
noid membrane, filling the space from the medulla oblongata to the 
sacrum ; and he is inclined to believe that this was the cause of the 
trismus. 4 

The results of post-mortem examinations made by Maturzinski are 
stated as follows : Out of twenty cases, he found in sixteen a semi-co- 
agulated fluid in the spinal canal between the dura mater and the ver- 
tebras; in some cases the fluid was limited to the cervical, dorsal, or 
lumbar region ; in many cases the coagulum, equally thick throughout, 
separated the membranes all round from the bony canal; the dura mater 
was healthy except in one or two places, where it was thickened and 
red ; the arachnoid was normal; the pia mater constantly much injected, 
and occasionally thickened ; the spinal marrow was very red in two 
cases, softened in one case, and indurated in another, but, with these 
two exceptions, perfectly healthy. 5 He agrees with Mr. Colles in attri- 
buting the disease to the condition of the umbilicus after the fall of the 
funis, aided by the action of cold. 

Dr. Sims, of Alabama, has published three very valuable papers on 
this disease, which I am sorry I omitted to notice in the former edition. 
His conclusions differ widely from those of the authors I have already 
quoted. He considers that trismus nascentium "is the result of mechan- 
ical causes ; the predisposing being protracted or tedious labor, but par- 
ticularly a too well ossified state of the foetal cranial bones. The exciting 
cause is undue pressure on these bones, more especially on the occiput: 
while the immediate cause is undue compression of the medulla oblon- 

1 Traits des Maladies de la Moder Epincire, vol. ii. pp. 106, 136. 

2 Dublin Journal, vol. vi. p. 467. 3 Dublin Journal, vol. xxv. p. 75. 

4 Mai. des Enfa'ns, p. 689. 6 Barrin, Mai. de l'Enfance, vol. ii. p. 478. 



TRISMUS NASCENTIUM. 99 

gata, and the nerves originating from it." 1 The cases he divides into 
two great classes, in one the occiput being displaced inwardly, with 
its edges overlapped by those of the parietal bones ; in the other the 
occiput occupied its natural position on the outside of these bones, but 
pressed upwards by the mode of decubitus, which in the latter was on 
one side or the other ; but in the former on the back, or in the semi- 
lateral position. 

In Dr. Sims's first paper he considered that this inward displacement 
of the occipital bone gave rise to congestion, and then rupture of the 
minute spinal veins ; and the post-mortem appearances in several cases 
seemed to justify the conclusion; but in the latter paper he has given 
up this opinion, and now considers the condition produced by both kinds 
of displacement to be pressure of the pons and medulla oblongata 
against the cuneiform process of the occipital bone, and that "the fifth, 
seventh, eighth, ninth pair of nerves are compressed, pinched, stretched, 
or thrown into folds, near their several points of convergence from the 
cranium ; and he takes great pains to show how the various symptoms 
would result from such pressure. The best argument Dr. Sims adduces 
is the success of his treatment, of which I shall speak hereafter. 

120. Thus we find, 1. That in certain cases presenting symptoms of 
trismus there is effusion of blood or serum in the spinal canal. 

2. That in similar cases there have been found traces of inflamma- 
tion, or its results. 

3. That in some cases, according to Dr. Sims, pressure upon certain 
parts of the cerebro-spinal system gives rise to symptoms of trismus, 
which are relieved by taking oft" the pressure. 

4. That, in the opinion of many careful observers, the condition of 
the umbilicus, after the fall of the cord, has an evident connection 
with the production of the disease. 

5. That some cases seem referable to irritation of the mucous sur- 
faces. 

6. That dampness, impurity of the atmosphere, cold, alterations of 
temperature, &c, have a very direct agency in the production of this 
disease, as is proved by the situations in which it prevails, and by the 
success of Dr. Joseph Clarke's preventive treatment. 

Professor Busch, of Berlin, and Dr. Levy, of Copenhagen, attribute 
the attack to inflammation of the umbilical arteries.; and the latter 
gives six cases with dissection, in confirmation of this opinion ; in all 
there was discoloration and suppuration of the coats of the arteries, 
and in some the coats were destined, but the division did not extend 
up to the point where the umbilical unite with the hypogastric arteries. 2 

Now, instead of trying to reconcile these differences of opinion, and 
to discover one cause for all cases, it appears to me much more philo- 
sophical to admit that there may be several which may give rise to the 
same symptoms. Those conditions which I have first communicated 
may be divided into centric and eccentric causes, and are very intelli- 

1 American Journal of Med. Science, for April, 1846, July, 1848, and October, 1848, 
p. 362. 

2 Brit, and For. Med. Review, vol. x. p. 275. 



100 TRISMUS NASCENTIUM. 

gible when explained by the discovery of Dr. Marshall Hall. The 
irritation from these various sources is conveyed by the excitor nerves, 
and its effects upon the spinal system are reflected by the motor nerves 
to the organs affected in the disease ; but there is nothing which could 
lead us to suppose that these effects must result from one local cause 
only. 

Whatever may be the exciting cause, there can be no doubt that the 
proximate cause is intense cerebro-spinal irritation, but which leaves no 
trace of disorganization in the brain or spinal marrow. 

Treatment. — A more intractable disease does not come within 
our observation. Dr. Collins remarks: "With respect to the treat- 
ment I have nothing to propose, as I have never seen an instance 
where the child seemed even temporarily relieved by the measures 
adopted. Calomel has been tried in large quantity, also in small 
doses often repeated, as well as extensive friction with mercurial 
ointment. I have tried frequent leeching along the spinal column, 
also repeated blistering over its entire length. Opium I have exhi- 
bited in many ways, both in very large and small doses ; also tartar 
emetic in the same manner, and at times both combined. I have tried 
tobacco extensively, in the form of stupes and injections of various 
degrees of strength, from one grain to the ounce of fluid, to five or 
more, besides the frequent use of the warm bath, oil of turpentine, 
tincture of soot, assafoetida, and many of the ordinary purgatives and 
stimulants; and all, as far as I could judge, without a shade of 
relief." 

121. In accordance with his view of the cause of this disease, Pro- 
fessor Colles advises that our attention should be directed to the um- 
bilical cord. He mentions that he had been informed that in Ja- 
maica, where this disease was formerly frequent and fatal, it is now 
rarely to be met with, and that the means used are, to plunge the in- 
fant daily into a cold bath, and daily to dress the umbilical cord with 
spirits of turpentine. He suggest that this might be tried here, and 
inquires whether tying the cord nearer to the abdomen might not induce 
a more healthy and active inflammation, by which trismus might be 
avoided. 

122. Dr. Breen seems to be more hopeful of the cure of at least 
some cases; his panacea is small doses of laudanum, with calomel 
and castor oil. "When the complaint develops itself, I order one 
drop of laudanum in an ounce of mixture, and of this I direct a tea- 
spoonful to be taken every second hour, until the patient appears to 
be affected with the narcotic properties of the opiate, which often hap- 
pens after the third dose; then the mixture is given less frequently. 
A grain and a half of calomel is also administered every fifth or sixth 
hour up to the third time, afterwards it is not given more frequently 
than twice or three times in twenty-four hours, with intermediate 
doses of castor oil, in the quantity of a large-sized teaspoonful, some- 
times joined with a third part of spirits of turpentine, which appears 
to me to quicken the action of the former. I also occasionally order 
three ounces of the assafoetida clyster of the Dublin Pharmacopoeia 
to be thrown up the rectum." Under this treatment the paryoxsms 



TRISMUS NASCENTIUM. 101 

diminish in force and frequency. Nurse's milk must be given, and 
as the effect of the opium is weakened by use, the dose must be in- 
creased ; but Dr. Breen has never found it necessary to give more than 
three drops in a two-ounce mixture. Occasionally at night he found it 
useful to substitute a grain of pulv. cretse comp. cum opio, with a 
grain and a half of calomel. He records two cases occurring in one year, 
that recovered under his own care by this plan of treatment, and one 
under the care of Dr. Graves. 

Gardien advises frictions with warm oil and laudanum, opium inter- 
nally, and counter-irritants. 

Dr. Schneider recommends a compound tincture of musk and amber- 
gris as having been of great use. The following is the formula em- 
ployed in the hospital at Bamberg: — 

R.— Anibr. gris. gj. 

iEther. vitr. §ss. 
Stet per hor. xij saspe agitando, dem adde, 

Mosch. gj. 

Liq. anod. Hoffm. 3 iij . — M. 1 

Mr. Chalmers mentions that he had succeeded in one case by a com- 
bination of rhubarb and musk. Barere and Bajon tried warm douches 
and cold baths, embrocations, oil of almonds, and syr. diacod., but in 
almost all cases were unsuccessful. 

Mr. Furlong succeeded in one case by giving at first a drop of lauda- 
num three times a day, and a warm bath four times a day, dressing the 
navel with turpentine and mercurial ointment, blisters to the nape of the 
neck, and two grains of Dover's powder with five grains of the sulphate 
of zinc. 2 He attaches much value to the zinc, but with such complex 
treatment it is quite impossible to say to which remedy we are to 
attribute the success. 

My friend Dr. M'Clintock suggests, and I think with sound reason, 
a trial of the tincture of the Indian hemp in this affection. He has tried 
it in a limited number of cases, and it seemed to lessen the severity of 
the fits, and retard the progress of the disease. 

In order to remedy the pressure produced by the occipital bone when 
displaced inwardly, Dr. Sims places the child on its side fully on a pil- 
low, and he states that the relief is obvious in most cases, but when in- 
effectual, he recommends that the top of the bone should be elevated 
and placed in its proper position outside the parietal bones. When the 
displacement is outward, the child should be held erect as much as pos- 
sible, and when laid down placed in the post-parietal position. I have 
no reason to believe that displacement is as frequent in those countries 
as Dr. Sims found it in America, but it is impossible to read his cases 
and doubt either that they were trismus, and that they were relieved if 
not cured by the relief from pressure afforded by the change of position. 

These, I think, are the principal modes of treatment, and very sad it is 
to think how ineffectual they generally are. The principles we should 
ever have in view are to direct our attention to the exciting cause of 

1 Edin. Med. and Surg. Journ., vol vii. p. 225. 2 Ibid., vol. xxxiii. p. 57. 



102 CHOREA. 

the irritation, and remove it if possible, and next to apply all our efforts 
to calm the irritation already excited. 

123. With a disease in which such faint hopes of a cure can be 
entertained, it becomes the more necessary to attend to such methods 
of prevention as have been found successful. Dr. Joseph Clarke's 
improved ventilation and attention to cleanliness, we have seen, had 
a striking influence in reducing the number of cases and in diminish- 
ing the fatality, which decrease has continued, under successive 
Masters of the Hospital, until the present time, by the adoption of 
similar precautions. Each ward of an hospital ought to have an ample 
supply of fresh, pure air, by day and night, with the means of escape 
for vitiated air. A moderate number of beds in each ward, so as not 
to overcrowd it, is also necessary. In the Western Lying-in Hospital, 
to which I have been many years attached, the disease is almost un- 
known. 

In private practice trismus nascentium is exceedingly rare, because 
the more obvious and frequent cause is seldom present; however, as it 
does occur, it will be well to try Dr. Breen's plan of treatment. 



CHAPTER IV. 

CHOREA. — ST. VITUS'S DANCE. 

124. The second name (St. Vitus's dance) given to this disease is 
said to be derived from a chapel at Ulm, built in honor of St. Vitus, 
who was himself affected with the disease, and which was visited in 
hopes of a cure by persons similarly afflicted. 

Without being limited to the period of childhood, it is nevertheless 
more frequent then than afterwards, occurring chiefly from the second 
dentition to puberty, or between the ages of seven and fifteen years, 
although we now and then see it in persons advanced in life : for exam- 
ple, Crampton met with it in a female upwards of forty years of age ; 
Copland in a man upwards of fifty ; Powell and Maton in females of 
seventy ; and Bouteille in one of eighty years. It is also three times 
as frequent in females as in males. 

"Everything is extraordinary in this disease," M. Bouteille observes 
in his preface ; " its name is ridiculous, its symptoms singular, its cha- 
racter equivocal, its cause unknown, and its treatment problematical." 
The definition given by Dr. Copland, in the learned article in his Dic- 
tionary, to which I have been much indebted, is the following : " Trem- 
ulous, irregular, involuntary, and ludicrous motions of the muscles of 
voluntary motion, more marked on one side than the other, without 
pain, occurring in both sexes, more frequently in the female, and chiefly 
between eight and fifteen years of age. 1 " 

1 Diet, of Pract. Med., Part i. p. S27, Art. Chorea. 



CHOREA. 103 

Chorea was known to the ancients, a disease closely resembling it 
having been described by Galen. It is noticed also in the writings of 
Plater, Horstius, and Sennert. From its striking peculiarities it has 
at different times been attributed to demoniacal possession, or included 
among feigned diseases, and an affection very like it seems occasionally 
to have prevailed epidemically in Scotland and America. 

125. Symptoms. — In some cases the attack comes on suddenly, 
without previous illness of any kind, but more frequently for some days 
the stomach and bowels are disordered, the spirits depressed, temper 
irritable, with frequent sighing. 

These symptoms are followed by irregular and involuntary motions 
or twitchings of the muscles of one side of the body, more frequently 
the left, or of one superior extremity, or of the face; very slight at first, 
but gradually increasing and extending to one of the lower extremities, 
so as to impede walking, or render it unequal or jerking. By and by 
these chronic convulsive movements involve the other side of the body 
more or less, and at length the tongue, so that the speech is interrupted, 
unequal, and imperfect. It is very possible that some cases of stam- 
mering 1 may in fact be a local species of chorea, and also those cases 
of incessant winking or twitching of the nose or mouth, which we meet 
occasionally, and which are so difficult to cure, although they often get 
well. I have at this moment under my care a little boy, very nervous, 
but healthy, who ordinarly winks about twice as often as other children, 
but if it be noticed, or if he be unusually earnest about anything, the 
eyelids are in incessant motion, and closed with unusual force. 

Stiebel has noticed this winking, as a modification of chorea, and he 
mentions also sneezing, rolling of the eyes, and a curious affection of the 
organs of speech, so that on awaking, the patient kept continually 
uttering a peculiar cry. Occasionally the hearing is affected, the child 
fancying that it constantly heard certain sounds. These local affec- 
tions may exist singly or along with the more general affection. 

The expression of the countenance undergoes a remarkable change ; 
in action it borders upon the ludicrous, but in repose it is almost idiotic. 
All the voluntary movements are distorted or impeded ; control and 
direction are all but impossible, as Sydenham observes : " Before a 
child who hath this disorder can get a glass or a cup to wet his mouth, 
he useth abundance of odd gestures ; for he does not bring it in a 
straight line thereto, but, his hand being drawn sideways by the spasm, 
he moves it backwards and forwards, till at length, the glass accident- 
ally coming nearer his lips, he throws the liquor hastily into his mouth, 
and swallows it greedily, as if he meant to divert the spectators." 2 

The movements of the lower extremities are generally less violent 
than those of the upper, but sufficiently so to render the walk uncer- 
tain, irregular, and jerking, obliging the child in some cases to keep 
constantly moving in order to avoid falling, and rendering him at all 
times insecure and liable to fall. There is more agitation of the lower 

1 Casper's Wochenschrift, 1837, No. i. 

2 Sydenham's Works, by Wallis, vol. ii. p. 430. 



104 CHOREA. 

limbs in bed than when up, evidently because the -weight of the body 
steadies them in the latter case. 

126. The muscles which support the head are also affected, so that 
it is sometimes bent forwards or backwards, or jerked towards one or 
other shoulder, or agitated with a rotatory movement. When the 
attack is very severe, the muscles of the trunk participate, and the 
body is jerked hither and thither so violently as to render confinement 
to bed necessary. 1 Rufz mentions a case in which the child threw itself 
out of bed, and crawled about the room like a worm. 2 Mr. Watt has 
related a case, in the Medic o-Chirurgical Transactions, of a little girl 
who was seized with an irresistible propensity to turn round on her feet 
like a top, then to lie down and roll rapidly backwards and forwards ; 
in a more advanced stage of her disease, while lying upon her back, to 
bend herself up like a bow, by drawing her head and heels together, 
and then suddenly to separate them, so as to cause the buttocks to fall 
with considerable force upon the bed, and to repeat this continually for 
hours: at a still later period she was seized with a propensity to stand 
upon her head, with her feet perpendicularly upwards : as soon as her 
feet gained the perpendicular, all muscular action ceased, and her body 
fell as if dead, her knees first striking the bed, and her buttocks striking 
her heels ; this was no sooner done than she instantly mounted up as 
before, and continued these evolutions, sometimes for fifteen hours 
successively, at the rate of from twelve to fifteen times in the minute. 3 

In mild cases of chorea, the irregular movements cease during sleep; 
but, when the attack is very severe, they do not cease entirely. 4 

So far, we have seen the convulsive motions affect chiefly the volun- 
tary muscles; but the muscles of organic life do not altogether escape. 
The rapid deglutition, the gulping down of fluids, is, doubtless, owing 
to a spasm of the pharyngeal muscles; and the peculiar cry, which 
some emit, to spasmodic action of the larynx. 

127. The general health may not be so much affected as we might 
expect, in simple chorea. The stomach seems capable of digesting 
food; the appetite, though occasionally capricious, is generally good, 
and now and then enormous. The bowels are most commonly regular 
and under control, although Berndt and Frank mention that they are 
occasionally moved involuntarily during a paroxysm. Dr. Copland 
states that the bowels are always constipated, and the abdomen some- 
what hard and tumefied. There is no febrile action when the disease 
is uncomplicated; the pulse is rarely quickened, the skin is cool, and 
there is no increase of thirst. Pain is seldom complained of, and but 
little general distress. Out of twenty cases related by M. Dufosse, 
eight suffered from slight headache, six from palpitations, and two from 
a pain, increased by pressure upon the spinous processes. M. Richard 
states that most of the girls he has seen affected with chorea presented 
a lateral curvature of the spine; and he seems inclined to attribute it 
to an overstretching of the nerves. Out of more than one hundred 

1 Rilliet and Barthez, vol. ii. p. 297. 

2 Archives Ge"n. de Med., 1834, vol. iv. p. 239. 

3 Condie on Disease of Children, p. 460, fourth edition. 

4 Stewart on Diseases of Children, p. 496. 



CHOREA. 105 

cases, M. Stiebel did not find one where there was not spinal irritation 
evidenced by tenderness in one or more vertebras. 

The temper of children laboring under chorea is very unequal; they 
are apt to be capricious, fretful, and easily frightened. Even a slight 
contradiction will bring on a paroxysm. In the majority of cases, when 
the attack is not prolonged, the intellect is scarcely affected; but if the 
disease be permanent, the mental power becomes weakened, or exercised 
fitfully and fancifully, and at length the patient becomes melancholy 
and silent. M. Gardien denies that it ever ends in idiotcy; but M. 
Rufz has related two cases in which it did ; and certainly the appear- 
ance of some chronic cases gives one the impression of their being very 
little removed from that condition. It is possible that in these extreme 
cases the imbecility may be owing to some organic change in the brain, 
as we also occasionally find the patient attacked by epilepsy or hemi- 
plegia; and Condie mentions that they are sometimes carried off by 
tubercular meningitis ; 2 but this can only be considered as a secondary 
disease. 

128. In the great majority of cases, chorea in children is an acute 
disease, increasing up to a certain point, then perhaps remaining sta- 
tionary for a time, and at length gradually subsiding. Its duration 
varies from two or three weeks to several months. The quickest reco- 
very Dr. Copland has ever known was eleven days ; M. Legendre's 
patient died in nine days. M. Rufz fixes the mean duration at thirty- 
one days, M. Dufosse* at fifty-seven days; and Rilliet and Barthez state 
the duration to range from six weeks to two months and a half. The 
latter careful observers saw but two cases that became chronic. 

Relapses, however, are very frequent. Dr. Copland saw it occur 
three times in the same patient, M. Rufz six times, and Rilliet and 
Barthez once, twice, and thrice in nineteen cases. 

Chorea most frequently terminates in a return to health, with a con- 
siderable increase in stature generally; but it may also end in convul- 
sions, epilepsy, palsy, ansemia, dropsy, hydrocephalus, or idiotcy; 2 and 
any of these attacks may prove fatal. Dr. Brown mentions three cases 
terminating in convulsions, coma, and death ; and Dr. Elliotson one 
which proved fatal from apoplexy. 

129. Complications. — The complications of any disease, or those 
secondary affections which arise in its course, are always of importance, 
and deserve most careful investigation, particularly in the diseases of 
children ; for they are often masked by the primary disease, and yet 
are occasionally the more fatal. On this account, I shall endeavor to 
lay before my readers these secondary attacks as accurately as I can, 
without deciding whether they are mere accidental complications, or, as 
in many cases, I believe, have a positive relation and dependence upon 
the primary morbid condition. 

Chorea is not unfrequently combined with hysteria, when it sets in 
at or soon after the eruption of the catamenia ; nay, it may assume 
very much the appearance of the latter; and there will also generally 

1 Diseases of Children, p. 455. 

2 Copland's Dictionary of Medicine, p. 328. 



106 CHOREA. 

be found some irregularity in the menstruation : it is either scanty, 
light-colored, irregular, or altogether absent. "The following proces- 
sion of morbid phenomena is not uncommon," says Dr. Copland. 
" Chorea, with defective action of the digestive, assimilating, and 
secreting functions, and torpor of the liver ; at a subsequent term, pro- 
tracted catamenia, or scanty and protracted appearance of the secretion, 
occasionally with various hysterical affections, seldom amounting to a 
complete fit of hysteria ; and, lastly, when the catamenia become esta- 
blished, the hysterical affection is sometimes more fully pronounced, 
and with the regular establishment of the uterine functions the chorea 
disappears." 1 

Dr. Copland was the first to demonstrate by post-mortem examination 
its complication with rheumatism, rheumatic pericarditis, and disease 
of the membranes of the spine, and his observations have since been 
confirmed by Drs. Pritchard, Roeser 2 and Nairne, 3 Trousseau, Begbie, 4 
Kirkes, 5 &c. 

Congestion of the brain, inflammation of its membranes, with serous 
effusion, tubercular meningitis, &c, have been detected by Soemmering, 
Browne, Coxe, Patterson, Serres, Condie, &c. It is not uncommon to 
have some of the febrile diseases of infancy, as measles or scarlatina, 
concurrently with chorea; and some difference of opinion exists as to their 
influence upon the original affection. M. Rufz says that "they exer- 
cise no influence upon either the duration or intensity of the chorea." 

On the other hand, Rilliet and Barthez state, that out of nineteen 
cases, nine were attacked by other diseases, and eight were evidently 
influenced by them; sometimes the chorea diminished from the com- 
mencement; in others it increased at first, and afterwards disappeared. 
They cite four cases from Legendre, Piet, and Rufz, in which measles, 
scarlatina, and smallpox occurred, and the chorea was cured. 6 

130. Pathology. — The post-mortem appearances which are recorded 
result from the complications or secondary affections, rather than from 
the primary disease. The body is generally emaciated, the muscles 
flaccid and pale, and occasionally we meet with lesion of the stomach 
and bowels, or slight effusion into the peritoneum. Dr. Hawkins found 
increased vascularity of the uterus, tubercles in the lungs, and earthy 
concretions in the mesentery, omentum, and pancreas ; Drs. Copland, 
Pritchard, and Roeser, adhesion of the opposite surfaces of the pericar- 
dium, with effusion of serum. In one case Dr. Pritchard observed 
the surface of the heart covered in parts with coagulable lymph, its 
cavities much enlarged, and their parietes thin, pale, and flabby. Dr. 
John Ware has related a case in which, after the pericarditis had lasted 
some little time, symptoms of chorea displayed themselves forty- eight 
hours before death. 7 

Soemmering, Brown, Coxe, Willan, Patterson, Guersent, and others, 

1 Dictionary of Medicine, p. 328. 2 Ibid. 

3 Lond. Journal of Med., January, 1851, p. 91. 

4 Ed. Monthly Journal, Jan., 1852, p. 363. 

5 Med. Gazette, 1850. 

s Mai des Enfans, vol. ii. p. 303. 
7 Amer.,Journ. of Med. Science, April, 1850. 



CHOREA. 107 

have detected marks of inflammation of the membranes of the brain, or 
of the brain itself, and also some foreign deposits in its substance or on 
its surface. In three cases M. Serres found inflammation of the tuber- 
cular quadrigemina, and in one a tumor resting on this part of the brain. 
MM. Monod and Hatin observed hypertrophy and vascularity of the 
brain and spinal cord, especially of the cortical substance ; Bright, 
turgescence of the brain and cord, with bony lamellce on the pia mater 
of the spinal marrow ; and Kein, ecchymoses of the membranes, with a 
pulpy state of the medulla. Dr Copland remarks : "In a case which 
occurred to me in 1819, complicated, or rather alternating, with 
rheumatism, with metastasis of this disease to the heart, and subse- 
quently to the membranes of the spinal cord, inflammatory appearances, 
with coagulable lymph and an effusion of turbid serum, were found 
through nearly the whole extent of their membranes ; the patient 
having died in a state of universal paralysis." " Dr. Aliprandi has also 
detailed a case, in which morbid appearances similar to those described 
by myself and Dr. Pritchard were found in the spinal canal." 1 

MM. Rilliet and Barthez observe, that in the great majority of cases 
no lesion of the cerebro-spinal system can be detected, their observa- 
tions so far agreeing with those of Black, Rufz, Gerhard, and Gendrin, 
&c. They mention some cases, however, in which there was great 
congestion of the membranes of the brain and spinal marrow, and one in 
which the latter was slightly softened, 2 as in two cases of M. Gendrin, 
one of M. Courtois, and three or four of M. Rufz. 3 Mr. Coley has also 
recorded the appearance of medullary meningitis, with softening. 4 Dr. 
Nairne has recently stated that he had seen four cases in which 
softening of the spinal marrow had been found in conjunction with 
chorea, but he did not think that the softening was the cause of the 
chorea. 

131. These opinions as to the nature of chorea, founded upon post- 
mortem examinations, are necessarily very various. They who have 
detected no morbid traces will regard it, with Sydenham and many 
others, as a nervous affection analogous to convulsions ; those who have 
observed morbid alterations will determine the seat and nature of the 
disease accordingly. So Bouteille, Clutterbuck, Lisfranc, &c, consider 
it to be inflammation of the cerebro-spinal axis ; Serres, as an affection 
of the corpora quadrigemina ; Bouillaud and Magendie, of the cere- 
bellum, &c. But we must carefully guard against the error of mistaking 
complicated forms of the disease for essential examples of it, and of 
generalizing from too small a number of cases. There can be no doubt 
that this, as well as other nervous diseases, may be either idiopathic or 
symptomatic : in the former, little or no organic changes will be dis- 
covered ; in the latter, merely those of the exciting cause. 

Dr. Marshall Hall observes 5 that " chorea is distinctly an affection 
of the true spinal system ; it affords an example of the want of har- 
mony between the cerebral and the true spinal acts ; volition is normal ; 

1 Diet, of Pract. Med., p. 329. 2 Mai des Enfans, vol. ii. p. 314. 

3 Barriere, Mai de l'Enfance, vol. ii. p. 434. 

4 Diseases of Children, p. 447. 

5 Diseases and Derangements of the Nervous System, p. 195. 



108 CHOREA. 

the true spinal action is abnormal. The action is abnormal or irregular, 
for want of a precise harmony between the two." Probably the explana- 
tion given by Dr. Copland is as correct as any; he states that "the proxi- 
mate cause of chorea, in its true and simple form, seems to consist of 
debility, with some degree of irritation of the organic or ganglial class 
of nerves, extended more or less to those of volition, and occasioning 
morbid susceptibility of the nervous system generally, with diminished 
power, increased mobility, and irregular actions of the muscular system, 
particularly of those muscles supplied with the nerves principally 
affected. Whilst this appears to be the pathological state of the 
majority of cases of chorea, yet instances not frequently occur, in 
which the disorder evidently commences in the spinal cord or its mem- 
branes, disturbing the functions of the nerves issuing from the affected 
part." 1 

132. Causes. — Among the predisposing causes, it would appear that 
sex has much influence, as we find the proportion of those attacked to 
be about three females to one male. In 240 cases M. Dufosse found 
seventy-nine male and 161 female children ; and Dr. Stewart states 
that in 174 reported cases there were 122 girls and fifty-two boys. 

The age most obnoxious to attacks of chorea is from six to fifteen 
years, and on this account it has been regarded as essentially connected 
with puberty ; 2 but this cannot be correct, for M. Constant saw a case 
of the disease at the age of four months, and M. Dufosse* one aged 
three years. M. Rufz gives a record of 189 cases: of these, ten were 
six years old, or under, and 179 from six to fifteen years of age. No 
doubt, as has been observed, this is a loose calculation, based upon hos- 
pital registries, which are not proverbial for their accuracy. Barthez 
and Rilliet mention nineteen cases: in three the first attack occurred at 
four years of age ; in one, at five ; in one, at six; in two, at seven ; in 
two, at eight ; in four, at nine ; in one, at ten ; in two, at eleven ; in 
one, at thirteen and a half; and in two, at fourteen years of age. 

I have already mentioned cases occurring at an advanced period, so 
that we cannot attribute as exclusive an influence to a certain age as 
some writers ; but, on the other hand, it cannot be denied that puberty 
may, and probably does, exert considerable influence. 

What effect climate may have is not very easy to determine ; the dis- 
ease appears to occur less frequently in southern countries, and in the 
West Indies is altogether unknown. 3 Children of a nervous tempera- 
ment, of great sensibility, and precocious intellect and passions, are 
generally considered to be more liable to chorea than others; but this is 
doubted by Elliotson, Rufz, Rilliet, and Barthez. It is certainly not 
confined to delicate children, for many of those attacked by it have pre- 
viously enjoyed excellent health. It may be doubtful whether we ought 
to consider chorea as an hereditary disease, although Coste, Young, and 
Constant, have each met an example, and Stiebel has known families in 
which every child was attacked at a certain age. 

1 Diet, of Pract. Med., p. 331. 

2 Gardien, Traite des Accouch., vol. iv. p. 269. 

3 Stewart on Diseases of Children, p. 495. 



CHOREA. 109 

133. According to some authors, e. g., Mezerai, Cullen, and Hecker, 
chorea has occurred epidemically. Albers, cited by Frank, mentions a 
school in which it appeared as an epidemic, and Rilliet and Barthez a 
village in the Tyrol in which it occurred recently. Dr. Copland has 
given an interesting section on nervous disorders resembling chorea; as 
the effect of the bite of the tarantula, the leaping ague of Scotland, and 
an affection which spread rapidly among a sect of religious enthusiasts 
in Tennessee and Kentucky, described by Dr. Robertson, &c. &c, which 
strikingly resemble chorea, and the extensive prevalence of which may 
have originated the idea of an epidemic. Dr. Wicke 1 states, that in a 
boarding-school at Eisenach the disease spread by imitation ; and it must 
be remembered that no disease is more likely to be imitated, and no class 
of persons more likely to become imitators, than those who are the fit- 
test subjects for chorea. 

Among the exciting causes are enumerated worms, dentition, fright, 
falls, or blows, according to Reeves, Bedingfield, Hall, Ecker, Rilliet, 
and Barthez, &c. Copland, Ploucquet, and Pritchard, attribute it to 
rheumatic metastasis to the membranes of the spinal cord; Darwin, Hay- 
garth, and Richter, to mental exercise, emotions, or passions. 

134. Diagnosis. — The pathognomonic characters of chorea are, per- 
manent, chonic, and, to a certain extent, voluntary movements, irregu- 
lar in direction and amount ; their cessation during sleep ; the conscious- 
ness and sensibility of the patient; and the age at which, and the mode 
in which, the disease commences. It is just possible that chorea may 
be confounded with hysteria, convulsions, paralysis, and delirium tre- 
mens. 

I. From the similarity of the age at which hysteria makes its first 
appearance, there may be some difficulty in the diagnosis of these dis- 
eases about the period of puberty, and especially at the commencement 
of a first attack, but none at an earlier age, for then hysteria is unknown. 
Moreover, as Dr. Copland has observed, chorea is often combined with 
hysteria in girls, and then, of course, distinction is impossible. But 
generally, hysteria occurs in more distinct periodic paroxysms, the 
movements less contorted, less ludicrous, quite involuntary, and gene- 
rally accompanied with globus hystericus, laughing and crying, and pale 
urine. 

II. In convulsions the movements are spasmodic, entirely involuntary, 
and much more violent, whereas the movements in chorea, though partly 
involuntary, are, to a certain extent, under the control of the will, and 
are in general modifications of voluntary motions. Further, in convul- 
sions, the patient is, for the most part, unconscious and insensible. 

in. When chorea is confined to one portion of the body — for instance, 
the tongue, on account of the difficulty of articulation, and the irregular 
protrusion of that organ — we may be led to suspect cerebral disease, 
but the speedy extension of the chorea will rectify our opinion; and 
when more of the body is affected, the preservation of sensibility, and, 
to a considerable extent, of motion, voluntary and involuntary, will pre- 
clude the possibility of supposing the case to be paralysis. 

1 Analekten der Kinderkranklieiten, Pt. viii. p. 89. 



110 CHOREA. 

IV. The age at which chorea occurs, so far, at least, as concerns my 
present subject, precludes, of course, the suspicion of delirium tremens. 

135. Prognosis. — The prognosis will mainly depend upon whether 
the chorea be simple or complicated, idiopathic or symptomatic. In the 
majority of simple cases it is favourable, although Rufz and Rilliet and 
Barthez have recorded two cases which terminated fatally. 

But when it is complicated with rheumatism, inflammation of the mem- 
branes of the brain or spinal marrow, convulsions, dropsical effusions, 
&c, the prognosis will be much more serious, and will depend, in a great 
measure, upon the extent and severity of the secondary affections, and 
upon the constitution of the child. Many fatal cases are upon record, 
although the majority recover. According to Joseph Frank, chorea, 
neglected, may lead to mania, apoplexy, paralysis, and consumption. 

186. Treatment. — The list of remedies which have been tried in this 
disease is long and varied, as the reader may see by referring to Cop- 
land's Dictionary. 

The indications of treatment must be founded on a careful study of 
each case, its characters, complications, &c. The first indication in 
simple chorea will be to remove fecal accumulations, and to correct any 
morbid condition of the intestinal canal; the second, to relieve nervous 
affections; and the third, to subdue the complications, if there be any. 

By many authors, purgatives alone are recommended, but, as Dr. 
Copland observes, a combination of purgatives with antispasmodic or 
stimulating remedies is much more efficacious. A full dose of calomel 
maybe given at first, followed, at intervals, by infusion of gentian and 
senna, or by an occasional dose of castor oil and turpentine. The fre- 
quency and continuance of the purgatives will be decided, in a great 
measure, by the character of the evacuations. But although we have 
abundant evidence of the success of this plan in this country, I ought 
not to omit to state that in France, according to Rilliet and Barthez, 
little or no confidence is felt in purgatives. Breschet recommends tartar 
emetic in full doses, but given so as not to excite vomiting. 

137. For the relief of the nervous affection, antispasmodics, narcotics, 
and tonics, are recommended. Valerian was first employed by Bouteille, 
and since by Murray, Guersent, and Jadelot, with success ; assafoetida 
has also been found useful. Oxide of zinc, gr. iij to gr. v, three times 
a day, originally given as a quack medicine in this disease, has been em- 
ployed by Duncan, Fouquet, La Roche, Wright, &c. Should it irritate 
the stomach, the addition of gr. ij. of the cuprum ammoniatum will cor- 
rect it, as Dr. Odier, of Geneva, has observed. Drs. Copland and Ba- 
bington consider the sulphate of zinc very useful, beginning with small 
doses, and increasing up to twelve or fifteen grains, three times a day, 
according to the latter physician. 

Frank, Uwins, and Crampton, have tried nitrate of silver, after pur- 
gatives, with great benefit in obstinate cases. Camphor has been recom- 
mended by Worlhoff, Mahon, &c. Other practitioners have given, suc- 
cessfully, Fowler's solution of arsenic, iodine, stramonium, prussic acid, 
belladonna, opium, &c. As, however, to be of any use, antispasmodics 
must be continued long, it will be well, after free purgation, to try those 
first which will admit of continuance, as valerian, assafoetida, oxide or 



CHOREA. Ill 

sulphate of zinc, &c; and in combination with some tonic, as in the fol- 
lowing formula, given by Dr. Copeland: — 

R. — Pulv. calumbae gr. x. 

" Valerianae gr. xij ad $j. 
Carb. ferri pp. gr. x. 
Pulv. cinnam. gr. vj. — M. 

Ft. pulv. vel elect, molle cum. syr. zingib. q. s. Bis vel ter quotidie 
sumatur. 

As a tonic, bark or quinine will be found most generally useful, and 
it may be given in the form of powder or decoction, or as a pill. Mar- 
ley recommends bark or calumba, with decoction of aloes, after a full 
dose of calomel and jalap, followed by moderate laxatives. 

Mead, Elliotson, Bateman, Baudelocque, and Bonneau, have obtained 
great success from preparations of iron ; Elliotson and Baudelocque 
prefer the subcarbonate, and Bonneau iron filings, in combination with 
quinine and a small portion of opium; and to the efficacy of the latter 
remedy Rilliet and Barthez bear ample testimony. 

Mr. Salter 1 has detailed successful cases treated by the liq. arseni- 
calis ; and Dr. M. Hall has added a similar case of his own, and one of 
Dr. Heming's. 2 

Drs. Peltz, Abney, and Baudelocque have lately tried iodine with great 
advantage. 3 

"Recently very decided testimony has been presented by Young, of 
Pennsylvania; Lindsay, of Washington; Hildbreth, of Ohio; Kirkbride 
and Professor Wood, of Philadelphia, and Bradle, of New York, in fa- 
vor of the cimicifuga in cases of chorea. It may be given in doses of 
half a teaspoonful of the powdered root three times a day ; or from one 
to two drachms of the saturated tincture ; or a wineglassful of the de- 
coction. 4 

Dr. Neumeister, of Arneburg, has published some cases successfully 
treated by a combination of the artemisia vulgaris and assafoetida 5 with 
a small quantity of the ol. animale Dippelii and tinct. castorei. 

138. When the convulsive movements are violent, incessant, and pre- 
vent sleep, there can be no hesitation in administering narcotics ; it is 
in such cases that opium, stramonium, hyosciamus, and belladonna have 
been recommended; but it will need great watchfulness and caution if 
the latter be exhibited, especially with young children. I should my- 
self much prefer opiates, as being more steady and certain in their 
effects, and less injurious. 

Cold baths have been much used by Petit, Jadelot, Dupuytren, and 
Marley, and sea bathing by Hufeland and Himly : but I agree with 
Biett and Copland that a shower bath, the patient standing in warm 
water, is more likely to be beneficial. Baudelocque substituted sul- 
phurous baths for simple water, and with good effects. They were easily 

1 Med. Chir. Trans., vol. x. 2 Underwood, p. 285. 

3 North American Med. Journal, vol. ii. 

4 Condie on Diseases of Children, fourth edition, p. 463. 

6 Journal fur Kinderkrankheiten, Jan. and Feb., 1851, p. 19. 



112 CHOREA. 

prepared by adding sulphuret of potash to the ordinary bath, and were 
taken every day, the patient remaining in the bath half an hour or an 
hour. Five out of eight patients thus treated were rapidly cured, 
according to Rilliet and Barthez. 

Counter-irritants have been recommended; blisters, setons, issues, 
and moxas have been tried; but the result does not seem very en- 
couraging. 

Electricity, or electro-magnetism, has been advocated by De Haen, 
Fothergill, Schaeffer, &c, and found useful in some obstinate cases by 
Meyraux, Addison, Bird, and others. Dr. Bird is said to have cured 
twenty-nine out of thirty-six, and to have afforded relief in five of the 
remainder. The electricity was applied in the form of sparks, in the 
course of the spine, every other day, for about five minutes at a time, 
until an eruption appeared. When the electric shocks were transmitted 
through the affected limb, the convulsive movements were increased ; 
and, if employed when the patient was convalescent, they reproduced 
the disease. 

"Trousseau has recently treated thirteen cases of chorea with strych- 
nine, ten of them with complete success. He employs the sulphate of 
strychnine dissolved in syrup, one grain to three ounces and a half; of 
this, two drachms and a half are given daily in three doses ; and the 
quantity is every day increased a drachm and a quarter until itching of 
the scalp and slight muscular stiffness are observed. The cure is gene- 
rally completed in one month." 1 

139. Opinions differ very much as to the propriety of bloodletting ; 
and it is not improbable that the difference may have been owing to the 
presence or absence of complications which would materially affect the 
result. Sydenham recommends bleeding to eight ounces, then three or 
four purgatives on alternate days, after which, he repeated the bleed- 
ing and purging, with an opiate at night, and a sufficient interval 
between each evacuation to avoid all danger. 2 Cullen says that it is 
sometimes useful, in other cases injurious. Watt found it decidedly 
useful, Armstrong injurious ; but Clutterbuck, Bouteille, Serres, and 
Lisfranc, recommend it. 

Its propriety will depend upon the evidences of congestion or inflam- 
mation in the brain or spinal marrow, indicated by pain, increased vas- 
cular action, heat of the head, coldness of the extremities, &c. ; then a 
few leeches behind the ears or along the spine, Or cupping, followed by 
cold affusion or irritating liniments, and warmth to the lower extremi- 
ties, will be highly proper. 

Believing the disease to result from pressure upon the spinal nerves, 
M. Stiebel rejects all the specific remedies, and applies leeches to the 
sensitive part of the spine, then mercurial ointment, counter-irritation, 
and, at a later period, cold shower baths. If this treatment do not 
relieve the complaint in two or three weeks, he suspends all remedies, 
and prescribes good diet, fresh air, &c. 

Marley 3 mentions that two of his patients who had resisted the usual 

1 Condie on Diseases of Children, p. 464, fourth edition. 

2 Works, vol. ii. p. 431. 

3 On Diseases of Children, p. 111. 



CHOREA. 113 

remedies, recovered on the occurrence of menstruation; and this will 
always be a ground of hope with girls affected with chorea. 

During the progress of treatment, the diet should be light and mode- 
rate, varying according to the constitution of the patient and the com- 
plications it presents. If there be evident inflammatory action, of course, 
low diet will be necessary; if, as is sometimes the case, the patient be 
nearly in a state of anaemia, full diet will be required. 

When convalescent, the patient will be greatly benefited by change 
of air and scene, and by the use of mineral, aperient, or chalybeate 
waters, according to circumstances. Sea bathing, with a free admixture 
of amusement, exerts a salutary influence. 

140. The complications will necessitate a change in the treatment. 
When rheumatism occurs, Dr. Copland observes, "it has generally been 
promoted by too lowering a treatment, but prevented by tonic and sti- 
mulating medicines, with due attention to the alvine evacuations. In 
cases, therefore, complicated with rheumatism, chlorosis, anaemia, or 
retention of the menses, the purgatives selected should be of a warm 
and stomachic kind, or combined with cordial and stimulating sub- 
stances — the ammoniated tincture of guaiacum, camphor, serpentaria, 
and similar substances, being also employed. In these states of disease, 
the internal use of the cod or tusk-liver oil will be found most beneficial. 
Having observed instances in which the suppression of rheumatic affec- 
tions of the joints, by the use of embrocations and liniments, was 
rapidly succeeded by the appearance of internal disease, the application 
of such remedies to the external seat of the rheumatic disorder should 
not be resorted to." 1 

When chorea occurs in girls after the age of puberty, and is com- 
plicated with hysteria and menstrual irregularity, it will be necessary, 
after evacuating the bowels, to attempt the regulation of the uterine 
functions by hip baths, emmenagogues, particularly preparations of iron, 
and perhaps by leeching the upper part of the thighs. 

When chorea is complicated with inflammation of the membranes of 
the brain, or of the pericardium, as these are far more dangerous, their 
treatment will to a certain extent supersede that for chorea. Antiphlo- 
gistics generally, bleeding, or leeches, calomel, and counter-irritation, 
will be indispensably necessary, modified in degree by the state of the 
constitution of the child, by the stage of the disease, and by the co- 
existence of chorea. Great care, great watchfulness, and a nice tact 
in the adaptation of remedies, will be necessary. For the method of 
treatment, I would refer the reader to the chapters treating of those 
diseases. 

1 Dictionary of Medicine, p. 335. 



114 CONVULSIONS. 



CHAPTER V. 

CONVULSIONS. 

141. There are few diseases of infants and children which are more 
formidable or more fatal than convulsions. They attack children of 
all ages, of different natural constitutions, and under very various 
circumstances, " sous toutes les latitudes, sous la zone brulante des tro- 
piques, eomme sous la zone glacee de Spitzberg. ,,x 

The disease has been variously classified, and with different meanings 
attached to the same nomenclature ; the essential distinction, however, 
being between an attack dependent upon disease of the brain or spinal 
marrow, and those cases where no such disease exists. These consti- 
tute the idiopathic and symptomatic convulsions of authors. Dr. 
Marshall Hall has proposed a more scientific division into centric and 
eccentric : " The former class would comprise all diseases of the brain 
and spinal marrow, complicated with convulsions ; the latter all those 
convulsive diseases which arise from teething, indigestion, deranged 
bowels, and which probably act through the fifth pair, the eighth pair, 
and the spinal nerves respectively, and constitute a part of a more 
comprehensive class of diseases, embracing affections of a series of 
nerves of what I have designated the reflex functions." 2 

I shall, however, adopt the more recent division into : 1, primary or 
essential convulsions, arising from irritation of various kinds, mental 
emotion, &c. ; 2, sympathetic convulsions occurring in the course of 
fevers, or organic diseases of any kind, excepting those of the brain or 
spinal marrow ; and 3, symptomatic convulsions, connected with 
diseases of the head or spine. 

142. M. Bouchut has given forty-one cases of convulsions : twenty- 
seven were essential or sympathetic, and fourteen symptomatic. Of 
the twenty-seven, fifteen were attacked in perfect health, and were 
cured ; but four of them died some months afterwards, of other diseases, 
and no structural alterations were detected in the brain : twelve occurred 
in the course of other complaints, as pneumonia, erysipelas, &c. ; seven 
of these died, and in one only was there any morbid appearance in the 
brain. He concludes, therefore, that " convulsions may occur, 1, in a 
state of health : 2, in the course of acute diseases, and in such cases 
are analogous to delirium ; and 3, that there is no relation between 
these convulsions and lesions of the nervous centres." 3 

MM. Rilliet and Barthez refer to twenty-five cases of sympathetic, 
and thirty-five cases of symptomatic convulsions ; but this apparent 

1 Brachet sur les Convulsions. 1824. 2 Underwood on Diseases of Children, p. 268. 
s Manuel Prat, des Mai. des Nouv. Nes et des Enfans a la Mammelle, p. 387. 



CONVULSIONS. 



115 



disproportion is explained by their not including in their report infants 
under a year old, and we know that primary convulsions are greater in 
infants than in older children. They have given the following table of 
the ages at which the patients were attacked. 1 



25 Cares of 


Sympathetic 




35 


Cases of 


Symptomatic 




Convulsions. 








Convulsions. 




] 8 months old there occurred 1 case. 


At 2 


yeai 


•s old there 


occur 


red 6 cases 


2 years 


" 


" 


4 cases. 


3 


" 




' 


" 


9 " 


8 " 


K 


" 


7 " 


4 


" 




' 


" 


2 " 


4 " 


" 


" 


4 " 


5 


" 




< 


" 


5 " 


5 " 


" 


" 


3 » 


6 


'< 




< 


" 


2 " 


6 " 


<< 


" 


5 " 


7 


« 




< 


" 


3 " 


7 " 






1 case. 


8 

9 

10 

11 


« 




< 


« 


1 case. 
3 cases. 

2 " 
2 " 



Taken altogether, primary convulsions are by far the most frequent 
during early infancy, and symptomatic convulsions at a more 
advanced age. 

14-3. Causes. — It has been stated that female children are more 
obnoxious to these attacks than males ; but this is very doubtful. As 
far as my own experience goes, I should say the contrary, and this 
accords with the observations of MM. Ililliet and Barthez. Of their 
twenty-five cases, fifteen were boys, and ten girls. The opinion, pro- 
bably, had its origin in the fact that nervous children seem especially 
predisposed to convulsions, but the distinction of sex as to temperament 
is not so decided in children as in adults. 

It is not very clear whether climate exerts much influence upon the 
disease. Mr. North seems to think that it does, and he quotes Dr. 
Hillary, who observes that the children of the island of Barbadoes are 
so irritable that they are thrown into convulsions by the slightest noise ; 2 
but we find convulsions equally prevalent, I think, in temperate, or 
even in cold climates. 

It certainly appears that convulsions may be hereditary and conge- 
nital. Boerhaave mentions that the children of an epileptic man all died 
of the same disease. Lorry relates the history of a family, of which 
the father, mother, and children were affected with convulsions from 
the slightest cause, notwithstanding that the children had been brought 
up separately, and educated differently. Baumes gives several similar 
cases. Guersent and Blache mention the case of a woman who was 
extremely passionate during pregnancy, and who lost three infants 
successively, from convulsions, soon after birth ; and Bouchut states 
that he knew a family of ten children, all of whom had convulsions, 
during infancy, ; one of them married, and had ten children, nine of 
whom had convulsions, and six died. 3 Among Rilliet and Barthez's 
cases two were children of an epileptic father, and a third had lost four 
brothers and sisters of convulsions. 

Mr. North attributes the congenital predisposition to convulsions in 



1 Mai. des Enfans, vol. ii. p. 278. 

3 Mai. des Nouyeaux Nes, &c, p. 392. 



2 North on Convulsions, p. 15. 



116 CONVULSIONS. 

many cases to feebleness on the parents ; to their marrying at too early 
or too advanced an age. 

If the mother, when pregnant, receive a great shock, a severe fright, 
or be subject to any other strong mental emotion, the child is often 
attacked by convulsions soon after birth. On the other hand, children 
born during an attack of puerperal convulsions are not necessarily affect- 
ed by the disease. I have seen a considerable number of such cases, 
where the infant was saved, and I am not aware of a single case which 
was subsequently attacked. 

The disease has occasionally prevailed as an epidemic ; in Paris, as 
described by Gualtier de Claubry, and in Copenhagen, according to 
Lange, where it was very fatal. 

The pressure exercised upon the head of the infant in its transit into 
the world, and " the natural state of increased vascular action in the 
brain, and the consequent excess of vitality, during its transmission from 
the soft mass to its regular organization, also imparts a strong predis- 
position to irregular nervous action, when an excess of action occurs, or 
any circumstance comes to interrupt the regular process of gradual 
development." 1 

144. The delicate condition of the brain, its transmission from qui- 
escence to organic activity at birth, and the concentration of stimula- 
tion from the senses and other organs, must naturally, one would think, 
predispose to the disease. 

The influence of temperament must not be omitted ; no doubt, nerv- 
ous, sensitive, and irritable children are more liable to convulsions, 
and perhaps those of a full plethoric habit ; but not these alone, for 
they not unfrequently attack infants in a state of anaemia, those, for 
instance, who have lost blood from the navel-string ; or weak, pale, 
delicate children, and those exhausted from excessive discharges. 

A large-sized head has been regarded as predisposing to convulsions 
by Desessart, Gardien, 2 and others, and popularly it is considered as a 
sure sign, especially if the forehead be prominent, and yet nothing can 
be less generally true. I have noticed many such cases, and have 
watched them carefully for many years, for the purpose of ascertaining 
the value of this opinion, and I have found it, as a rule, useless and 
untrue. " Levret, Baumes, and other writers," says Mr. North, 
" affirm that it maybe established as an axiom, that children born with 
large heads, or whose heads increase in size disproportionably to the 
other parts of their bodies, will have convulsions. In my own practice 
I have seen convulsions occur very frequently in children with small 
heads. In rickety children the size of the head is disproportionately 
large; and from the general symptoms of rachitis, it is evident that the 
head and spinal marrow are considerably affected: the brain increases 
rapidly in size, the senses are usually very acute, and convulsions are 
very frequent attendants of this distressing malady. It not un- 
frequently happens, that when some children of the same parents are 

1 Stewart on Diseases of Children, p. 483. 

B Traite des Accouchemens, &c, vol. iv. p. 250. 



CONVULSIONS. 117 

affected with rachitis, others, who are exempt from this disease, are at 
a very early age destroyed by convulsions." 1 

145. The exciting or occasional causes are very various. Shame, 
anger, and fright have been known to induce an attack. North relates 
a case of a child thrown into fatal convulsions by the nurse threatening 
to throw him out of the window if he did not cease crying. It has 
been attributed to tight bandaging, a pin piercing the child, 2 excessive 
mental emotion, a loud noise, sudden exposure to a bright light, hot, 
impure air, or severe cold. Guersent and Blache mention their occur- 
rence in children confined in a hot chamber, or in a crowded and hot 
theatre, for some hours; and Brachet states that a little girl, being ex- 
posed to a severe cold for eight or ten minutes, was seized with difficulty 
of breathing threatening suffocation, followed by convulsions. 

During the first year of life, convulsions may not unfrequently be 
traced to the milk of the mother or nurse disagreeing with the infant, 
or having been disordered temporarily by fright, passion, or suffering. 
Soemmering mentions a curious case of a woman whose milk agreed 
with her own child, but caused convulsions in all others. M. Guersent 
relates an instance of a woman deserted by her husband, and in her 
distress her infant had an attack each time it took the breast. Dr. 
Underwood mentions a mother who nursed her child immediately after 
witnessing a sudden death ; the child was attacked by convulsions, after 
which it remained comatose for thirty-six hours, but ultimately recover- 
ed. 3 Numerous cases are on record of convulsions supervening upon 
violent passion in the nurse. I have witnessed more than one case 
resulting from the mother suckling her child during a time of severe 
affliction and distress. 

It is said that the exhibition of soothing medicine by the nurse, 
such as Godfrey's cordial, syrup of poppies, &c, may bring on an 
attack. 

146. At a later period dentition is certainly a very frequent cause ; 
the distension of the gums, the pressure, the intense congestion, occa- 
sion so much irritation, that an attack of convulsions is a common result. 
This is the case particularly with lively, sensitive, nervous children, 
although the more quiet and phlegmatic do not always escape. I have 
repeatedly observed in these cases a sort of gradation from simple irri- 
tation and restlessness to starting, surprise, wildness of look, partial or 
local convulsive movements, and lastly, general convulsions. 

Or the attack may be caused by derangement of the stomach and 
bowels, from retention of the meconium or urine, from too much or too 
thick food, from eating indigestible matters, the improper use of stimu- 
lants, &c. ; or it may result from the diarrhoea consequent upon these 
errors of diet. One of my own children was attacked by severe diarrhoea, 
followed by reaction, high fever, and convulsions. It was remarked to 
me by Dr. Charles Johnson, one of the most accurate observers and 
judicious practitioners I have ever known, that such cases are generally 
more manageable than others, and so I have found it. I have also 
known them result from renal disturbance. 

1 On Convulsions, p. 11. 2 Richard, Mai. desEnfans, p. 541. 

3 On Diseases of Children, p. 258. 



118 CONVULSIONS. 

By many authors an attack has been attributed to worms, and Brachet 
relates a case of convulsions which was owing to a worm in the meatus 
auditorius. Cerise and Barrier admit the influence of suppressed normal 
or morbid secretions or eruptions in the production of convulsion, 
although the latter thinks that it has been exaggerated. Certain it is 
that an eruption of crusta lactea on the head has been repeatedly found 
to cure the disease. 

Too long continued or too long suspended exercise of the senses may 
equally give rise to convulsions in infants, and too much mental excite- 
ment and exertion in children of more advanced age. The attempt to 
press forward the education of children is, in fact, an excess of stimu- 
lation to the brain, and is attended with the greatest risk. 

147. So much for the causes of primary convulsions. Sympathetic 
convulsions frequently usher in organic diseases, or eruptive fevers, as 
scarlatina, measles, &c. ; and Sydenham and Bouchut are rather disposed 
to regard it as a favorable occurrence. It is remarkable, however, that 
in these cases we have one or two convulsions only, scarcely ever a fre- 
quent repetition of them, and this I think will enable us to distinguish 
the convulsions ushering in an eruptive fever from others. Barrier 
mentions three cases of pneumonia, commencing in this manner, and 
the fact is noticed by many writers. 

Or they may occur in the course of organic diseases of the chest or 
abdomen, particularly towards their termination, from their amount of 
irritation, or from exhaustion. The latter attacks are analogous to the 
convulsions from ansemia. 1 

Mauthner remarks: "I have often observed, in cases of extensive he- 
patization or tuberculization of the lungs, during the course of which 
the brain was perfectly unaffected, that the children, a few days before 
death, lost all chest symptoms; that the cough and orthopnoea seemed 
to have entirely vanished, their appetite returned, and they seemed 
cheerful; when convulsions suddenly came on, followed, in a few hours, 
by death." 2 

Dr. Simpson has suggested that albuminuria may occasionally give 
rise to convulsions, and he mentions a case of convulsions in an infant 
on the third day after birth in whose urine he detected albumen. 3 

From the mechanical interruption to the regular central circulation, 
it is not uncommon to have convulsions in the course of croup or hoop- 
ing-cough, nor do I know a more unfavorable complication; the child is 
generally not in a condition to bear active treatment, and even if we 
succeed in allaying the convulsive attack for the time, it is almost cer- 
tain to return if the cough continue. 

Convulsions may occur at the termination of any of the organic dis- 
eases, and in such cases the result is generally unfavorable, whether the 
sympathetic irritation be of an active kind or result from exhaustion — 
"a repletione aut ab evacuatione" — according to Hippocrates. 

148. Symptomatic convulsions may result from various cerebro-spinal 
diseases; congestion and inflammation of the membranes; effusion of 

1 Denis, Recherches sur plusieurs Mai. des Enfans, p. 325. 

2 British and Foreign Review, No. 42, Ap. 1848, p. 892. 

3 Ed. Monthly Journal, Oct., 1852, p. 874. 



CONVULSIONS. 119 

fluid ; inflammation and softening of the brain or cord ; abscesses, tumors, 
or spiculse of bone making undue pressure upon any part, &c. &c. We 
shall enter more fully upon this question by and by when treating of 
these diseases. 

149. As to the proximate cause or pathological condition of the nerv- 
ous system in convulsions, some confusion has arisen from the distinction 
between primary or sympathetic and symptomatic convulsions not hav- 
ing been always observed. In the former classes very little information 
is obtained by a post-mortem examination, the knife of the anatomist 
being inadequate to the detection of functional derangements, or of dis- 
turbances, however serious, which result from irritation only. 1 In the 
majority of cases of primary or sympathetic convulsions, no change can 
be discovered in the brain or spinal marrow, or in their membranes ; in 
others there may be a degree of congestion or vascularity, but whether 
this precedes or follows the attack of convulsion is not quite clear. In 
some cases the brain exhibits an anaemic condition. 

In symptomatic convulsions we shall find the traces of the primary 
disease of the nervous centres: "Inflammation of the membranes of the 
brain, sharp spiculse of bony matter formed in the dura mater, abscesses 
in the brain, or effusion of blood into its substance from external vio- 
lence, are the appearances recorded by some of the older physicians. 
Effusions of serum, vascular turgescence, tumors attached to the mem- 
branes, or imbedded within the substance of the brain, are noticed by 
more recent writers. Turgescence of the vessels, a deep red color of 
the dura and pia mater, and effusion of blood beneath the cranium, are 
the appearances described by De Claubry. Vascular turgescence at 
the origin of the nerves distributed to the muscles that had been affected 
with convulsive movements, has been noticed by Moulson. Effusion of 
serum, or of a gelatinous matter, engorgement of the bloodvessels, ex- 
travasation of blood, abscesses, tumors, and inflammation of the menin- 
ges of the brain, are the lesions described by others. Effusion of blood 
within the spinal canal, engorgement of the vessels of the brain, and 
extreme venous congestion of the entire substance of the brain, with 
serous effusion, were met with by Horner in one case, and the same 
appearances, with extreme mollescence of the brain, in another. Tur- 
gescence of the vessels of the brain, its substance of a pink color, with 
serous effusion into the ventricles at the base of the cranium and with- 
in the theca of the spine, are noticed by Kennedy." Dr. Condie states 
" that in every instance in which we have examined the brain, after 
death from convulsions, more or less disease of that organ, or of the 
medulla oblongata or spinalis, was present. In most cases this amounted 
to simple but very extensive hyperemia, with slight effusion of serum 
beneath the membranes, or within the ventricles; in other cases partial 
softening of the brain was very evident; tubercles were frequently 
detected, either meningeal or within the substance of the brain ; and in 
a few cases of effusion of blood upon the surface of the brain, at its basis, 
or within the theca of the spinal marrow." 2 

150. Symptoms. — The mode of invasion varies a good deal in primary 

1 North on Convulsions, p. 41. 2 Condie on Diseases of Children, p. 400. 



120 CONVULSIONS. 

convulsions. In the majority of cases the infant is dull, heavy, and 
feverish, for a day or two previously, or it may he restless and irritable 
with an uncertain oscillation of its eyes, or an occasional wide stare ; 
grinding its teeth, starting in its sleep, or awaking in a fright ; disordered 
and irregular respiration; loss of appetite; thirst, and spasmodic turn- 
ing in of the thumbs, and bending of the wrists, or ankle-joints, as 
described by Dr. Kellie. 

In other cases there are no precursory symptoms; the child is attacked 
when perfectly well, occasionally in his sleep ; or suddenly in the course 
of other diseases, with no circumstances which would lead us to antici- 
pate convulsions. 

When first seized, the child has a bewildered, surprised, frightened 
look; its eye expresses terror; the globe is agitated with irregular jerk- 
ing movements. Sometimes the pupil is turned upwards, sometimes 
downwards ; then, perhaps, it is for a moment steady, until drawn to 
one side or the other ; the parallelism of the two eyes is lost, and the 
child squints horribly ; sometimes the pupil is contracted, in other cases 
it is dilated ; and frequently, from the turning upward being excessive, 
the iris is invisible, giving a frightful expression to the face. 

"The effect of light upon both pupils is not always similar; one may 
remain fully dilated, while the other contracts ; or one pupil may remain 
stationary, the other being alternately contracted and dilated. I am 
not aware that the remark has been made before, but I believe, from 
frequent observation, that when a light is applied close to the eyes, and 
the same effect is not produced upon both pupils, that we have much 
reason to fear some serious affection of the head." 1 

The muscles of the face are thrown into irregular and distorted action ; 
the mouth, cheeks, &c, are twitching and jerking in different directions ; 
sometimes the jaws are forcibly closed, or only moved laterally, so as 
to grind the teeth. The child froths at the mouth, and the respiration 
has a short, broken, and hissing sound. 

151. If the attack be very slight, the convulsive movements may be 
limited, or nearly so, to the face, but in general the trunk and extremi- 
ties speedily become involved. The head is thrown strongly backwards, 
or to one side, or it is rapidly rotated from side to side ; the muscles 
of the back are rigid, or act with sudden and irregular jerks; the arms 
are demiflexed, and thrown about irregularly ; the hands are clenched, 
with the thumbs turned into the palm, and twisted or forcibly flexed or 
rotated. The lower extremities are similarly affected, but more slightly, 
and the feet are generally flexed upwards and inwards. 

I have already stated that the respiration is quick, broken, and sibil- 
ant, from the quantity of mucus in the mouth. Occasionally it is very 
irregular, a series of rapid breathings being followed by a long rest, 
then a deep inspiration, and immediately after the rapid respiration. 
This may be partly owing to disordered innervation, and partly to mus- 
cular disturbance. 

The pulse is accelerated, ranging from 110 to 140 or 160, generally 
small and hard, and often irregular. The action of the heart is dis- 

1 North on Convulsions, p. 70. 



CONVULSIONS. 121 

turbed, the rhythm and force of its contractions being frequently 
modified. 

The face becomes florid, sometimes violet ; the head is hot, the feet 
cold, and a clammy moisture soon breaks out over the body, but particu- 
larly upon the head and face. 

Intelligence is wholly, and sensation partially suspended ; the child 
recognizes no one, in most cases it does not see at all ; a loud noise or 
a brilliant light produces no effect, but the sense of touch, though 
impaired, is not lost. 

If the attack be violent, the internal muscles share in the disorder, 
and the urine and feces are evacuated unconsciously. 

The duration of the fit varies very much, lasting but a few seconds 
in some cases, in others from five minutes to ten or twelve hours. 1 

At length the convulsive movements relax, and ultimately cease, and 
the child falls into a state of general relaxation ; the face becomes pale, 
the eyelids closed, the limbs flaccid, the respiration quiet and regular, 
the pulse slower and weak, and sleep supervenes. From this sleep the 
infant awakes feeble and exhausted, but generally conscious and intelli- 
gent. 

152. Variations. — The above is an imperfect sketch of an ordinary 
convulsion; it would be almost impossible to describe the multiplicity 
of combinations, and the endless variations we meet with in practice. 
Some of the more ordinary deviations, however, I must notice. I have 
already mentioned that in many cases there are no premonitory symp- 
toms ; this is the case with primary convulsions, and also with sympa- 
thetic; in the latter there will be present the symptoms of the organic 
disease, but the fit may supervene quite unexpectedly, whether at the 
beginning or the end. When it ushers in the eruptive fevers, the child 
will show more or less evidences of fever, and, perhaps, but not always, 
some evidence of the head being involved. In symptomatic convulsions 
there will generally be ground for anticipating a fit, although it may 
occur suddenly. 

Again, the convulsion may be much slighter than the one I have 
described, consisting of momentary unconsciousness, with sudden invol- 
untary movements, something like a violent rigor ; or even less marked, 
the body becoming rigid, the eyes fixed and staring, the hands clenched, 
and almost immediately a return to the natural state. I remember a 
case in which measles was ushered in by a fit as slight as this, but was 
accompanied or followed by an optical delusion, the child fancying that 
he saw dogs jumping on the bed : the fit did not return, but the vision 
of dogs recurred occasionally for some time. 

In other cases the convulsion is partial ; one part of the body only 
being affected, sometimes one-half ; in other cases the face only, or the 
eye, or a more distant set of muscles ; and these local or partial attacks 
are apt to lead the young practitioner to undervalue the disorder, and 
to treat the case feebly and inefficiently. 

Ordinarily the fit terminates in sleep, and on waking the child is 
heavy and exhausted ; occasionally there remains some weakness of one 
or both limbs, with a peculiar expression about the eyes. 

1 Eilliet and Barthez, vol. ii. p. 269. 



122 CONVULSIONS. 

In some cases it is cut short by what appears to be a critical evacua- 
tion, as in the cases related by Planque, 1 Condie, 2 and others, in which 
hemorrhage occurred from the mouth, nose, and ears ; by diarrhoea, 
according to Whytt, 3 Jacques, 4 &c. : or by vomiting or epistaxis, accord- 
ing to MM. Brachet and Bouchut. 

In primary and sympathetic convulsions, the first attack is sometimes, 
though not always, the only one, but in symptomatic convulsions there 
are generally several. The interval between them varies from half an 
hour to a day or two ; the symptoms of each fit are the same, and the 
termination similar, unless they prove fatal. Rilliet. and Barthez 
remark, that the duration of each fit is longer, and the severity greater, 
in symptomatic than in sympathetic convulsions, and that they occur 
more frequently in the night. 

153. Under proper treatment, a good proportion of cases of primary 
convulsions recover ; the fits either do not return, or they become 
weaker, the intervals longer, and then cease altogether, and the child 
gradually recovers its health. In some of the most successful of such 
cases, I have seen, however, two consequences of the attack, which 
remain for a considerable time ; one is an obliquity of vision, not, per- 
haps, amounting to a squint ; and the other a degree of insecurity in 
walking or running, so that a very slight obstruction will occasion the 
child to fall. More serious effects, however, are not uncommon ; 
Brachet mentions, as a consequence of convulsions, pains in the limbs, 
ecchymoses, rupture of the tendons, luxations, fractures, and curvature 
of the bones. 5 

Bouchut states that he has seen wry neck, drooping eyelid, squinting, 
distortion of the mouth, and contraction of some of the limbs ; 6 but in 
sixty cases Rilliet and Barthez did not find a single case of this kind. 

Dr. John Clarke mentions the occurrence of paralysis after one or 
two convulsions, 7 from which, after some time, the child may partially 
or wholly recover ; and Dr. Hamilton, chronic epilepsy, chorea, idiocy, 
imbecility. 8 

Or an attack of convulsions may localize itself, as it were, and 
become partial ; thus I have seen spasm of the glottis supersede general 
convulsions, by which it was preceded and complicated. 

Mr. Thompson, of Whitehaven, has recorded a case in which loss of 
hearing and speech occurred after a fit of convulsions, and were not 
recovered for many years. 

Children who recover from convulsions are very liable to a relapse 
from even a slighter degree of the same causes, or from others of less 
severity, but this susceptibility ceases in a few years. 

When convulsions occur at the commencement of eruptive or ordi- 
nary infantile fever, the child may run through them very safely 
notwithstanding. Hippocrates observes that convulsions followed by 
fever terminate happily. 

1 Bibliotheq. Med., vol. iii. p. 504. 2 Diseases of Children, p. 400. 

3 On Nervous Diseases. 

4 Journ. Gen. de Med., vol. xxis. p. 280. 

5 Traite des Convulsions, p. 46. 6 Mai. des Enfans, p. 400. 

7 Comment, on Diseases of Children, p. 83. 

8 Hamilton on Diseases of Children, p. 88. 



CONVULSIONS. 123 

154. Sympathetic convulsions occurring in the course or towards the 
end of other organic diseases, are a serious addition to the danger ; the 
> former may subside, but the latter generally terminate the disease 
fatally. The frequency of this occurrence will explain the dispropor- 
tionate amount of cases of convulsions in the list of mortality. 

In some cases the attack has terminated in a state (probably of partial 
asphyxia) which has been mistaken for death. Brachet mentions a 
child which recovered after having been abandoned as dead. Mr. North 
relates a similar case which occurred to Dr. Johnson ; and Bouchut 
refers to one in Paris : the child was put into its coffin, and placed in 
a " chapelle," but the next morning it was found sitting up and playing 
with the ornaments by which it was surrounded. I need hardly say 
that the stethoscope will enable us to settle this question correctly. 

Lastly, the intensity and frequency of the fits may augment instead 
of diminishing, and so terminate fatally. This, according to Brachet, 
" may occur in two ways, either primarily through the brain, which, 
being over-excited, ceases to act upon the other organs, hsematosis does 
not take place, and death is certain ; or primarily in the lungs, in which 
case respiration, impeded by the irregular and violent contractions of the 
respiratory muscles, is imperfectly performed; the lungs become con- 
gested, the blood only circulates partially through them, suffocation is 
threatened, and does take place if more regular efforts do not restore 
the respiration and circulation. Lastly, syncope may occur, and be so 
prolonged as to prohibit a return to life." 

So far, these are modifications of the ordinary kind of convulsion 
only. I shall notice a very curious variety, which has been called 
Salaam convulsions by Sir C. Clarke, and Eclampsia mutans by Mr. 
Newnham. It is a very rare disease. I believe Mr. West was the first 
in these countries to bring it under the notice of the profession. Sir 
C. Clarke had seen but three cases in his practice, up to 1839, and Dr. 
Locock only one. Mr. Newnham has published four cases 1 (including 
Mr. West's); another has been related by Dr. Willshire; 2 two others 
have been published in the London Journal of Medicine, translated from 
the German, 3 and two have been described by Dr. Faber. 4 A case very 
much resembling this affection is described by Dr. Wright, of Montreal, 5 
but it appears to have been connected with catamenial disturbance. 

The essential symptom of the disease, is a bowing forward and down- 
ward of the head, so as sometimes almost to touch the knees ; at first 
the movement is slow, but it increases in frequency until it attains great 
rapidity, so much as to be repeated fifty or 140 times in succession ; 
when so rapid it degenerates into a mere nodding of the head. The at- 
tack, in some cases, is preceded by sleepiness, heaviness about the eyes, 
or casting them upwards. An attack not unfrequently comes on after 
awaking from sleep, and in other cases the child seems worn for sleep, 
which may be disturbed by spasms or screaming. Sooner or later other 

1 British Record of Obstetric Medicine, No. 6, vol. ii. p. 3. 

2 London Journal of Med., June, 1850. 

3 Journal fiir Kinderkrankheiten, March, 1850. 

4 Medico-Chir. Review, July, 1851. 

5 British American Journal, April, 1850, p. 311. 



124 CONVULSIONS. 

automatic movements occur, and the attack may ultimately involve 
general or local convulsions, paralysis or idiocy. 

In Dr. Newnham's first case, the child was attacked by paralysis, and 
her intellect became weak, but she ultimately recovered. The second 
case (Mr. West's) became idiotic, although the bowing ceased. In the 
third, there was partial paralysis of the upper extremities, with intellec- 
tual deficiency, and the fourth ultimately died, the attack continuing 
with intervals nearly to the end. 

In Dr. Willshire's case there was neither paralysis nor permanent in- 
jury to the intellect, and the patient recovered under the treatment 
adopted. 

One of the cases recorded in the Journal der Kinderkrankheiten 
became epileptic and semi-idiotic; the other improved under the use of 
iron. I shall take the liberty of giving some of Mr. Newnham's conclu- 
sions, as he has seen more of the disease than any other practitioner. 
He says : "This affection appears to be spinal in its origin; for although 
it will have been established by the foregoing cases that, previously to 
the attack, there had been some peculiar expression of the eyes, and some 
degree of heaviness, or of unwonted irritability, yet, as all the earlier 
phenomena are spinal, it must be classed as an eccentric affection; and 
the little disturbance of the cerebral manifestations may be explained 
by the reflex irritation of this morbid spinal agency which has com- 
menced, is proceeding, but has not reached that culminating point at 
which it interferes with the established harmony of the voluntary or 
semi-voluntary muscles. Though spinal in its origin, it will have been 
noticed that in every instance general convulsions will soon make their 
appearance, and cerebral symptoms will occur. The effect upon the 
manifestations of mind is most marked, consisting not in a simple arrest of 
development and defective nutrition, for then it would remain just as when 
the disease supervened, whereas it will have been seen that a desolating 
influence is at work; a morbid action has been established; and although 
this shall seem to be at rest for a time, and the mind shall grow during 
intervals of freedom from the attack, yet on a renewal of the distress- 
ing symptoms, it will be seen that the downward action is progressive, 
that the early sparklings of intelligence are obscured, and that the mis- 
chievous influence is proceeding surely, to the extinction of intellect in 
fully formed idiocy. 

" Not only have the manifestations of mind been blighted, but in 
many instances paralysis has been a consequence, either in the form of 
paraplegia or hemiplegia; the kind of paralysis therefore has not been 
uniform, though in some form or other, and in a greater or less degree, 
it has been invariable. 

"It is to be remarked that in each of the recorded cases, the severe 
attacks of the peculiar bowing have always been preceded by sleep ; 
they have been always noticed to occur with especial severity in the 
morning after the night's sleep, or after the customary morning nap. 

"There is evidently in this malady a family alliance with epilepsy, 
and hence, as has been demonstrated by the foregoing cases, it often 
passes into epilepsy, or some other form of infantile convulsions. Te- 
tanoid symptoms do also sometimes occur during its progress. 



CONVULSIONS. 125 

"There are some differences in the phenomena described, which it 
would be right to notice : a. During the paroxysm the hands were closed 
in Nos. 2 and 3, but they were expanded in No. 4, showing, that in the 
former cases, irritation of the flexor muscles, in the latter of the exten- 
sors, was predominant, b. The throwing the head backward in No. 2, 
appears only to have been a consequence of muscular and general feeble- 
ness, whence the head, from its own weight, fell backward for the want 
of adequate support, c. In No. 2 the irritation of the decaying teeth 
seems to have been the greatest in 1843, when the peculiar bowing af- 
fection was relieved ; but in No. 4 the bowing affection was aggravated 
when teething irritation was greatest. 

"The fondness for music, pictures, or gay colors, has been so marked 
in some of the above cases, that it should be noticed, as it shows that 
the injurious impression has not been made upon the organs of sense, 
and as the judicious employment of these senses would form a most im- 
portant part of the future educational treatment, because affording large 
inlets of knowledge, and to the development of sentiment and affec- 
tion." 1 

Mr. Newnham inclines to the opinion that the essential character of 
the disease is inflammatory action of a weak and strumous nature, of 
the membranes investing the medulla oblongata, afterwards extending 
to other parts. 

Dr. Willshire considers it probable that the disease is purely centric 
in its origin, having its first seat in the sensorium, or in those import- 
ant parts placed between the "hemispheric ganglia" and the top of the 
spinal cord, and afterwards in the lower or non-sensorial portion of 
the spinal apparatus, as proved by the general automatic movements 
being in some cases of a decided tetanoid character. In others these 
movements were distinctly epileptiform, and moreover hemiplegia has 
followed, the former circumstance still further indicating, as the seat of 
mischief, the assemblage of ganglionic centres between the cerebrum 
and spinal cord, whilst the latter and the supervening affection or obli- 
teration of the intellectual powers appears to prove the secondary in- 
volvement of the great hemispheric lobes. The essential peculiarity of 
the disease, Dr. Willshire thinks, may be some change in the circulation 
of the minute vessels of a scrofulous character. 

155. There is a species of convulsive affection which has been de- 
scribed by Jadelot and Guersent, and which is deserving of notice. It 
is not a general convulsion, but a tonic contraction of the muscles of the 
upper and lower extremities. It is observed in young infants, and also 
in children approaching the age of puberty. The wrists and fingers be- 
come remarkably rigid, both being partially flexed, and when the lower 
extremities are also affected, they are stretched out instead of being 
bent. The muscles are felt to be rigid and tonic, and their outline may 
be distinctly traced underneath the skin. 

The tonic contraction may continue for hours or days, and in some 
cases it has lasted for years, but its duration is generally shorter. It 
may cease spontaneously, or under the influence of treatment, and re- 

1 British Record of Obstetric Med., vol. ii. No. 6. p. 18. 



126 CONVULSIONS. 

turn. It is seldom accompanied with disturbance of other muscles, or 
of the intellect, respiration or digestion. The pulse is sometimes, though 
rarely, contracted. 

It is evidently a disease of reflex irritation, and may in general be 
traced to a gastro-intestinal irritation of some kind, or to dentition, or to a 
vitiated atmosphere. It rarely terminates fatally, and in cases where an 
autopsy was made, neither Jadelot nor Guersent found any appreciable 
alteration in the brain or spinal marrow. 

Diagnosis. — I. From Epilepsy. A single convulsion and a single 
epileptic fit resemble each other so closely, that it would be difficult 
to point out any marked distinction ; there may be a difference in 
the intensity and extent of the convulsive movements ; in the sudden 
onset and frequency of the fits ; in the history of the case and its 
termination ; but time is, after all, the principal test, the course of the 
two diseases being very different. 

II. From Chorea the distinction is easy, for in it the motions are 
slighter, not altogether involuntary, nor accompanied by insensibility. 
Even at the commencement of an attack of chorea there is but little 
resemblance to the involuntary violent motions, partial or general, of 
convulsions, and there is no loss of consciousness. 

156. But the diagnosis of the cause of the convulsions is of far 
greater importance, as Rilliet and Barthez have observed, than the 
differential diagnosis. 

Suppose we are called to a child from one to six years old, strong, 
and hitherto healthy, who has had a convulsion following a fright, blow, 
fall, indigestion, &c. The convulsion may, of course, be primary, 
sympathetic, or symptomatic, but upon further inquiry we find that the 
child was perfectly well up to the moment of the attack, that the ex- 
citing cause is plain, the constitution sound, the access not very violent, 
and that there are no other head symptoms. So far, then, the case is 
one of primary or sympathetic convulsions ; but further investigation 
proves that there is no disease of the chest, abdomen, &c, and we con- 
clude that the convulsions are primary or essential. 

But if, on examination, we discover evidences of pectoral or abdomi- 
nal disease, acute or of long standing, we must then infer that the 
convulsions are sympathetic, and we cannot be too minute in our ex- 
amination of all the organs in every case, as the treatment as well as 
the diagnosis will depend upon it. In these primary and sympathetic 
attacks the brain and nervous system are only in a state of sympathetic 
irritation, in most cases, but we cannot be quite sure of this when the 
fit comes on in the course of some chronic disease, as, for instance, in 
tuberculous affections, in which it is quite probable that the brain may 
be the seat of a similar deposit. Such cases render the diagnosis very 
difficult. 

After six or eight years of age, it is rather rare to find a child at- 
tacked with either primary or sympathetic convulsions; they are almost 
always symptomatic of disease of the nervous system. MM. Balliet 
and Barthez state that, with one exception, all the twenty-five cases of 
sympathetic convulsions observed by them were under seven years of 



CONVULSIONS. 127 

age. 1 Moreover, the absence of adequate exciting causes, the freedom 
from organic disease of the chest and abdomen, -will exclude the pri- 
mary and sympathetic forms, and we shall generally be able to detect 
other symptoms of head disease existing at the time, and previously, in 
addition to the convulsions. 

157. Prognosis. — The prognosis in primary convulsions will depend 
upon their intensity and frequency, upon the age and strength of the 
patient, and in some degree upon the cause ; for instance, when they 
arise from indigestion, cold, &c, they are less dangerous than when 
they are caused by a fright or wound, or any mechanical cause. 

If the attacks be partial or slight, with long intervals, without much 
acceleration of the pulse or congestion about the face and head, and 
with recovery of intelligence during the intervals, the child will almost 
certainly recover; but if they be general, with a quick pulse, great 
congestion, and a frequent repetition of the fit, the danger is very 
great. I have no doubt that Bouchut is right in stating that primary 
convulsions are the least fatal. 

Sympathetic convulsions have a more serious character, because of the 
complication ; the child has to contend not merely against the affection 
of the nervous system, but against the organic disease giving rise to it, 
and the danger is more than doubled. Moreover, in some complications, 
as in hooping-cough, for example, the original disease is a perpetually 
recurring cause ; each fit of coughing throws so much stress upon the 
brain, that the convulsions are reproduced at the very moment when 
they seem to have been relieved. 2 

The convulsions which occur in the course of fever, and which assume, 
as it were, the place of delirium, are rather favorable, according to 
Sydenham ; and certainly those which are preceded, and perhaps caused 
by diarrhoea are more manageable than the other varieties of sympa- 
thetic convulsions. 

In symptomatic convulsions the prognosis is always serious, and 
generally unfavorable when they occur in the course of the disease of 
the nervous system ; less so when at the commencement. 3 

Mr. North remarks, that the younger, and the more susceptible the 
child, the less is the danger, and also that they are less serious in girls 
than in boys. 

158. Treatment. — In proceeding to treat a case of convulsions, we 
should first ascertain to which of the varieties it belongs, whether it is 

1 Rilliet and Barthez, Mai. des Enfans, &c, vol. ii. pp. 274, 275. 

2 " Inasmuch as convulsions are a frequent attendant on diseases of the brain, it is 
certainly very natural to turn our attention first to the nervous centre. It often happens, 
however, if much care be not taken to investigate a case thoroughly, that leeches and 
cold applications to the head are hastily ordered, and calomel given, when the presence 
of pneumonia is afterwards detected, or some cause of gastric disturbance found to exist, 
without due attention to which no permanent amendment can result from any treatment. 
Inflammations of the chest are peculiarly liable to lead into this kind of error. Their 
real symptoms are marked by convulsive seizures ; the medical attendant fancies on the 
first day that the case is one of inflammation of the brain, on the next day he thinks it 
must be pneumonia, and thus the uncertain diagnosis leads to vacillating treatment, and 
much mischief is the result." — Mauthner on Diseases of the Brain, $c, in Children, British 
and Foreign Review, April, 1846, p. 392. 

3 Rilliet and Barthez, Mai. des Enfans, vol. ii. p. 277. 



128 CONVULSIONS. 

primary, sympathetic, or symptomatic; we must bear in mind, also, the 
constitution of the child, its previous state of health, previous attacks, 
&c. &c. The treatment also will vary in some degree according as we 
are called during the fit, or during an interval. 

If we see the child during a fit of partial convulsions, our first duty 
is to remove any exciting cause which may be present. Thus, all tight 
bandages should be loosened, all pins removed, the dress made quite 
easy, and the child placed in a recumbent position, exposed to plenty 
of fresh air. 

If the gums be swollen or congested, they must be freely lanced down 
to the teeth, and beyond those teeth which are pressing forward. If 
we do not cut deeply or extensively enough, very little relief will be 
afforded. 

After this the child should have a warm bath for a few minutes, and 
then be carefully dried, and wrapped in a warm blanket. 

159. It may be that these measures will relieve the paroxysm, but 
whether or not, the next question is as to the propriety of abstracting 
blood. Almost all writers are in favor of it, and whatever experience 
I have had only confirms their opinions, with very few exceptions. If 
the convulsion be very slight or partial, if there be no flushing of the 
face, no quickening of the pulse, it is probable that lancing the gums, 
a warm bath, and a smart purgative, may be sufficient. Again, in some 
cases of sympathetic convulsions, in the course of, or at the termination 
of other organic diseases, when the infant is much reduced, it may not 
be able to bear the additional loss of blood ; in such cases we must have 
recourse to counter-irritation. Lastly, in symptomatic convulsions, the 
propriety of bloodletting must be in a great measure determined by 
the nature and extent of the original disease. 

But in severe cases of primary convulsions, when the pulse is quick, 
the face and head flushed, and the paroxysm well marked — in sympa- 
thetic convulsions, at the commencement of diseases of the lungs or 
abdomen — in the febrile diseases of children, or during their course, if 
the child be strong — and in symptomatic convulsions, at the outset of 
cerebral disease — there is no doubt in my mind that a liberal application 
of leeches is of the greatest service. It is not enough to apply one or 
two leeches, but, e. g., to a child of a year old, six at least ought to be 
applied, and the bleeding stopped token the leeches detach themselves. I 
must strongly protest against the ordinary plan of allowing the leech- 
bites to bleed indefinitely; more blood is thus often lost than was intended, 
and it is quite impossible to form any precise estimate of the quantity 
desired or actually taken, unless by arresting the hemorrhage at a 
given time. If the convulsions return, the leeching must be repeated, 
nor need we fear for the child if it be strong and healthy; there is more 
danger of our not bleeding sufficiently than of the other extreme in 
these cases, especially in cases of threatened meningitis. My friend 
Dr. M'Donnell's child, of four months old, was attacked by meningitis 
ushered in by violent and almost incessant convulsions. I applied 
eighteen leeches in the course of twelve hours with perfect success ; the 
convulsions altogether ceased after the last application, and the child 
recovered. 



CONVULSIONS. 129 

As to the best situation for applying the leeches, some advise the fore- 
head or behind the ears, others the back of the hand or foot, the ankles, or 
the anus. I prefer the forehead as being nearer the seat of the disease, 
and requiring fewer leeches to produce an equal impression, and because 
it is easy to stop the bleeding. North advises that " blood should be 
drawn from the jugular vein, or from the temples by cupping." 

160. At the same time we may diminish the vascular action of the 
brain by the application of cold lotions or ice in a bladder. Dashing 
cold water upon the face will sometimes terminate the fit ; and next in 
efficacy to this, according to Dr. John Clarke, is the effluvia of volatile 
alkali plentifully inhaled. 1 

For the purpose of preventing or diminishing cerebral congestion, 
MM. Dezeimeris and Trousseau have proposed compression of the caro- 
tids, and, it is said, with success. Drs. Bland and Stroehlin have 
published some favorable cases, 2 and Mr. North thinks favourably of it 
in cases of great weakness and exhaustion. Barrier, however, states 
that it rarely succeeds. 

161. So far the remedies I have mentioned may be employed during 
the paroxysm ; our treatment, however, must be continued during the 
interval of quiet which succeeds. The repetition of leeching must be 
decided by the repetition of the convulsion, or the occurrence of slight 
convulsive twitchings, or of much starting in sleep. If these are absent, 
and if the infant sleep calmly, no further leeching will be necessary ; 
but measures must be taken to act briskly upon the bowels by means of 
calomel and jalap, or rhubarb, castor oil, infusion of senna, &c. Or a 
purgative enema may be given in order to produce the effect more 
quickly, or whilst the child is unable to swallow. The advantage of 
evacuating the bowels is twofold ; any indigestible or irritating matter 
is removed, and we establish a derivation from the brain. Dr. Condie 
speaks highly of the effects of spirits of turpentine in cases dependent 
upon derangement of the alimentary canal, and my own experience 
amply confirms his observation; combined with castor oil it acts promptly 
and beneficially. 

M. Brachet recommends calomel pretty largely; two grains every 
two hours. Mr. North objects to this ; but although I have not given 
it in the full doses recommended by M. Brachet, I have certainly found 
benefit from smaller ones, say half a grain three times a day, in combina- 
tion with as much Dover's powder, and a grain of James's powder. 

Next to intestinal derivatives, those applied to the surface are 
the most effectual. Fomentations of hot water with mustard to the 
feet and legs, and blisters to the neck, upon the head, or behind the 
ears, will be advisable. Mr. North recommends mustard sinapisms to 
the feet ; Sydenham a blister between the shoulders ; Dr. John Clarke 
one to the calves of the legs, or between the shoulders. The blister 
should not be applied too soon ; it will be quite time enough after the 
baths, leeching, and the free evacuation of the bowels ; I think also 
that a succession of small blisters is much preferable to one large one : 

1 Commentaries on Diseases of Children, p. 109. 

2 Med. Chir. Journal, April, 1839. 



130 CONVULSIONS. 

a narrow strip may be applied across the forehead, then one behind 
each ear, or, if necessary, the upper part of the head may be shaved 
and then blistered. 

With children of delicate constitution, or who have been much 
exhausted by any cause, leeching is sometimes impossible, and then our 
principal reliance must be upon a succession of blisters. 

When the attacks are often repeated, so that the disorder becomes 
chronic, I have seen great benefit result from a seton of three or four 
silk threads in the arm, and continued for some time, particularly in 
the convulsions arising from dentition. 

An argument for the use of counter-irritation to the scalp has been 
derived from the fact, more than once observed, that convulsions have 
ceased on the appearance of an eruption of crusta lactea. Professor 
(Ettinger has recommended that the eruption should be produced by 
inoculation, but a blister will act just as effectively. 

M. Husson states that he has relieved convulsions by vaccination. 

Dr. Grantham considers non-ossification of the fontanelles as one cause 
of convulsions, which he proposes to remedy by compression of the 
head generally, with a calico bandage applied moderately tight, and he 
quotes one case in which he succeeded. 

162. Antispasmodics of various kinds have been strongly recom- 
mended; by German writers camphor and valerian are especially praised, 
by others ether, assafoatida, musk, bismuth, ammonia, &c. Drs. Under- 
wood 1 and Stewart 2 speak very highly of musk given freely, that is, 
from half a grain to two grains every two hours. Dr. John Clarke, 
however, states, that he has seen no good effects from any, with the 
exception of ether and ammonia : " It does not appear to him that 
they derive any additional good quality from mixing them with assa- 
fcetida, valerian, castor, musk, tinctura fuliginis, amber, and other fetid 
substances." 3 How far the inhalation of ether in certain cases may be 
advantageous is as yet unknown ; I am inclined to think, however, that 
it might be beneficial after the removal of the exciting cause, and when 
the fits are not accompanied by high vascular action. I have used it 
in a case of convulsion complicating hooping-cough, with apparent 
benefit. My friend Dr. Simpson has also used it with perfect success in 
the case of an infant five weeks old, who had had severe convulsions for 
nearly a fortnight, allowing him to wake for food ; he was under its 
influence for nearly twenty-four hours, and emerged from the sleep per- 
fectly well with no return of the fits. Mr. Williamson, of Manchester, has 
recorded the case of an infant six weeks old, whom he kept constantly 
under the influence of chloroform for sixty hours, sixteen ounces having 
been used and with complete success. 4 

Dr. Locock speaks highly of the subcarbonate of iron in cases where 
the child has been much exhausted by other diseases. 

The oxide of zinc has been much relied upon by M. Zangerl, who 
gives one and a half to three centigrammes every two hours ; by M. 
Brachet, who combines it with the extract of hyoscyamus, ten centi- 

1 On Diseases of Children, p. 264. 2 On Diseases of Children, p. 493. 

8 Comment, on Diseases of Children, p. 108. * Lancet, June 11, 1853, p. 535. 



CONVULSIONS. 131 

grammes of the former and twenty of the latter in the twenty-four 
hours ; and by MM. Guersent, Blache, and Barrier. 

163. Narcotics have been sometimes advised, but they are rarely 
necessary, and when given require great watchfulness in their adminis- 
tration ; perhaps the best mode is to combine a little Dover's powder 
with calomel or James's powder. Mr. North recommends Dover's pow- 
der when the infant is restless, with startings and twitchings. Brachet, 
Blundell, Condie, and others, prefer hyoscyamus, either alone or in 
combination. The external application of opium has also been advised. 

If used at all, we would begin with very small closes, watching their 
effects, and only increasing them very gradually. They should never be 
given when the pulse is full, when there is much fever, general plethora, 
or determination to the head. When diarrhoea is present, or when the 
nervous irritability is very great, I have seen them very useful. 

Dr. John Clarke remarks : " It requires the greatest consideration 
and the exercise of great circumspection to determine when and in what 
quantity opium may with propriety be exhibited in convulsions. It 
may fairly, however, be laid down as an axiom, that it should never 
be employed on any account, until it is clearly ascertained that no 
danger is likely to arise from pressure on the brain ; that there is not 
any existing inflammation of that organ ; and never until the bowels 
have been completely unloaded, lest the stupor arising from a com- 
pressed brain should be attributed to opium ; and the time when alone 
relief could have been given in inflammation of the brain should be 
allowed to pass by, never to be recalled. When the medical attendant 
has reason to believe that no danger is to be apprehended from any of 
those circumstances, opium in small doses, cautiously repeated, may be 
administered with advantage, and it will sometimes diminish pain by 
lessening the sensibility and irritability of the patient. Great care 
must, however, be taken, during the use of it, to keep the intestinal 
canal free. 1 Dr. Russell, of Limerick, has mentioned to me, that he has 
derived great benefit from the use of prussic acid, in doses of one-twelfth 
of a drop every hour, and in a few cases in which I have tried it, 
it seemed to soothe the child and diminish the convulsion. It is particu- 
larly suited to cases of convulsions complicating hooping-cough. 

Alkaline medicines will be of service, when we are satisfied of the 
presence of acid in the stomach. 

164. Thus we find that primary convulsions may be arrested and 
relieved by cold affusion, warm baths, bleeding, &c, after removing all 
apparent causes; that during an interval the principal remedies are, 
perhaps, a repetition of the bleeding, purgatives, counter-irritation, anti- 
spasmodics, and narcotics; and that in a chronic state of the disease, 
when the fits are repeated, great benefit is derived from a permanent 
drain upon the constitution. 

But a little deviation from the ordinary treatment is often advisable. 
When the patient is delicate and weakly, or run down from other dis- 
eases, it may be necessary to give tonics and stimulants: Barrier and 
others speak highly of ammonia. In some cases we are obliged to give 

1 Comment, on Diseases of Children, p. 108. 



132 CONVULSIONS. 

wine, with great caution, however, and nourishing diet ; in other cases a 
change of air is highly beneficial, or, if the infant be suckling, a change 
of nurse : this is strikingly the case when hooping-cough is complicated 
with convulsions. 

In sympathetic convulsions, the treatment of the secondary affection 
must necessarily in a great measure depend upon the state of the pri- 
mary disease and the condition of the child. In the majority of cases 
we shall have to content ourselves with measures of less activity, such 
as counter-irritation, cold to the head, antispasmodics, &c; leeches or 
cupping will only be admissible in few cases. But as a compensation, 
we shall generally find that the remedies which benefit the original dis- 
ease will relieve the convulsions. In febrile diseases ushered in by fits, 
however, the local treatment may be pretty active. 

The same observations will apply to symptomatic convulsions, except 
those cases where the convulsion ushers in the disease, or occurs at a 
very early period in an inflammatory affection; then, indeed, so far from 
diminishing the activity of our treatment, we must rather increase it. 
The convulsions which accompany the chronic organic diseases of the 
brain require delicate management, and a nice adjustment of remedies, 
but of these I shall speak at length when I treat of those diseases. 

The treatment of eclampsia nutans so far has not been satisfactory. 
Every species of irritation must be removed, the gums lanced, bad teeth 
removed, the bowels freed, the diet regulated, &c. The food should be 
nutritious, but unstimulating, and as far as may be of a dry character, 
according to Mr. Newnham. Calomel and preparations of steel seem to 
have been beneficial in some of Mr. Newnham's cases, and rather in- 
jurious in others. Prussic acid seems to have palliated the symptoms, 
and opium to have aggravated them. 

Dr. Willshire's remedies were blisters behind the ears, keeping the 
bowels freed by castor oil, and the internal exhibition of the iodide of 
potassium and the disulphate of quinine. 

In one of Dr. Faber's cases, purgations, baths, cold effusions, antispas- 
modics, embrocations, &c. ; all failed to mitigate the disease, and in the 
other little or no benefit was derived from frictions to the nape of the 
neck with tartar emetic ointment; quinine and antispasmodics, cold 
effusions, and warm douches seemed to do harm, but the patient improved 
somewhat under the use of iron. 

The treatment for tonic convulsions of the extremities consists of 
frictions and warm or vapor baths, and gentle purgatives. M. Jadelot 
recommends cold effusions, frictions with ether or tincture of digitalis, 
and internally camphor or valerian. M. Guersent advises frictions with 
a liniment containing laudanum, and if this fail, laudanum internally. 
Diaphoretics have also been recommended, and the sesquicarbonate of 
iron in large doses. With patients of a full habit, venesection may be 
necessary. 

Contrivances for the extension of the limbs may be tried in conjunc- 
tion with warm baths, emollient frictions, and in some cases they seem 
to have succeeded. Section of the contracted muscles has been proposed, 
but it seems to me a very unscientific proceeding, and I believe has not 
been attended with any success. 



CONVULSIONS. 133 

165. The diet of children attacked by convulsions should in general be 
simple and bland; milk in any form, rice, arrowroot, &c, will be 
suitable and sufficient until the severity of the disease is subdued. Ani- 
mal food and wine should in general be prohibited, except, as I have 
already said, where there is great exhaustion, or in some cases of sym- 
pathetic convulsions, In them it may be necessary to allow a little 
broth. 

Cool, fresh air in a large room is very desirable, and in many cases 
assuming a chronic character a complete change of air is most beneficial. 
I need not dwell upon the necessity of a warm, loose dress, and the re- 
moval of everything which can irritate. 

But perhaps the most important and most neglected hygienic arrange- 
ment is perfect quietness; the nervous system has been so shattered 
that quietness is essential to its recovery, and yet if there be any im- 
provement the nurse and parents are so delighted, that they invariably 
set about amusing and exciting the child, to obtain renewed evidence of 
its restoration. The room should be darkened, and nothing done to 
excite the child; the longer it sleeps the better. 

166. As to the consequences of convulsions, little direct treatment is 
necessary; the weakness of the limbs or of one side will in most cases 
gradually diminish ; gentle frictions or salt water baths may be employed, 
and, with country air and exercise, will generally succeed. 

In like manner the squinting gradually diminishes in many cases: 
for the more marked cases various contrivances have been proposed. 
Mr. North relieved it by an ivory instrument, covering each eye, and 
pierced with a minute aperture ; or we may sometimes succeed by tying 
up the sound eye, and using the distorted one. Dr. Jurin prefers the 
following method: "Place the child before you, and let him close the 
undistorted eye and look at you with the other. When you find the 
axis of this eye fixed directly upon you, bid him endeavor to keep it in 
that situation, and open his other eye. You will immediately see the 
distorted eye turn away from you towards his nose, and the axis of the 
other will be pointed at you; but with patience and repeated trials he 
will by degrees be able to keep his distorted eye fixed upon you, at least 
for some little time, after the other is opened; and when you have 
brought him to continue the axes of both eyes fixed upon you as you 
stand directly before him, change his posture; put him first to one side 
of you, and then to the other. When in these different situations he 
can perfectly and readily turn the axes of both eyes towards you, the 
cure is effected." 1 

1 North on Convulsions, p. 215. 



134 ACUTE HYDROCEPHALUS. 



CHAPTER VI. 

ACUTE MENINGITIS — ACUTE ARACHNITIS — ACUTE HYDROCEPHALUS. 

167. The disease I purpose describing in this chapter has been 
termed by some dropsy of the brain, water in the head, internal hydro- 
cephalus ; by Cullen, hydrocephalic apoplexy ; by Macbride, hydro- 
cephalic fever ; by Bricheteau, hydrocephale aigue ; by Gardien, Capu- 
ron, and others, fievre cerebrale ; by Brachet, hydrocephalite ; by Rufz, 
Piet, Guersent, Green, Barrier, Rilliet and Barthez, &c, meningite 
tuberculeuse ; by the Germans, hitzige gehirnhohlenwassersucht. 

By whatsoever name described, and however various the theories as 
to the nature of the disease, it appears to me that both the symptoms 
and the post-mortem appearances indicate an affection of the mem- 
branes of the brain as the essential character of the disease, whether 
primary or secondary ; and as that affection exhibits evidences of 
inflammation or of its results, I prefer using the simple terms prefixed 
to this chapter. Modern writers, indeed, particularly the French, have 
drawn a marked distinction between acute meningitis and tubercular 
meningitis ; but as the distinction during life is in many cases impos- 
sible, and in almost all very obscure, I have thought it better to include 
both under the one name, and to describe them as two (out of many) 
phases of the same disease. 

168. The earliest record of the disease is by M. Duvernay in 1701, 
and by Messrs. St. Clair and Paisley in 1782-3, in the Edinburgh 
Medical Essays. In 1768, Dr. Whyte's essay " On the Dropsy of the 
Brain" was published, and as a minute and accurate description of the 
disease, it is admirable, but his pathological reasoning is incorrect. In 
the same year, Dr. Fothergill and Dr. Watson read their papers on the 
subject to a society in London, and afterwards published them in the 
fourth volume of the Medical Observations and Inquiries. The former 
physician regarded the disease as incurable, and so would Dr. Watson 
but for one case of recovery, which hardly appears to have been owing 
to the treatment. A case of hydrocephalus internus, published by Dr. 
Dobson in 1775, was the first in which mercury was used, and as it was 
successful it made a considerable impression, and led to the general use 
of this remedy in the disease. As yet the theory of Whytt and others, 
that the effusion of fluid into the ventricles depended upon debility of 
the vessels, or an attenuated state of the blood, prevailed. In 1779, 
however, Dr. Charles Quin published an inaugural essay, founded upon 
information derived from his father, Dr. Henry Quin, an eminent phy- 
sician of this city, in which he attributed the disease to determination 
of blood to the brain, to increased arterial action, and effusion of fluid 
as a consequence. The practical result of this theory was the em- 



ACUTE HYDROCEPHALUS. 135 

ployment of antiphlogistic remedies, as venesection and cold applica- 
tions to the head. In a more advanced stage of the disease he recom- 
mended mercury, on the principle laid down by Dobson, for the purpose 
of stimulating the absorbents of the brain. This essay was afterwards 
enlarged into a treatise. Dr. Withering, in his Account of the Fox- 
glove, published in 1785, agrees with Dr. Quin in regarding the disease 
as inflammatory, and the effusion as the consequence, not the cause, of 
the illness. 

Dr. Rush, in the Medical Observations and Inquiries for 1789, 
added some important information to the previous knowledge of the 
disease. Admitting the occurrence of primary hydrocephalus, he 
showed that it may be caused by other diseases ; and he carried blood- 
letting to a greater extent than his predecessors, even affirming that 
hydrocephalus may be cured by the lancet. In 1791, Dr. Perceval, 
of Manchester, published a valuable paper in the first volume of the 
Medical Tracts and Observations, containing a post-mortem examina- 
tion of a case in which death took place before effusion, and recom- 
mending the combination of opium with calomel. Dr. Garnett, in 
1801, maintained that the disease consists in a plethoric state of the 
vessels of the brain, occasioning a considerable degree of inflammation, 
and generally, though not always, giving rise to effusion. In 1808, 
Dr. Cheyne's first essay was published, confirming the value of mercury 
in the disease, and clearly establishing the secondary character of some 
varieties of hydrocephalus. To this work, confessedly of very high 
value, I shall refer more particularly by and by. Although at this 
time it was pretty well agreed that the disease was inflammation, there 
continued to be some dispute as to its exact locality, although Briche- 
teau and others regarded the effusion as the principal phenomenon. 
Golis (1815), Piorry (1822), placed the seat in the arachnoid; Coindet 
in the cerebral ventricles ; Brachet in the lymphatics ; Abercrombie in 
the brain ; M. Senn (1825) in the pia mater, and he first applied to it 
the term meningitis ; M. Piorry (1823), and MM. Parent-Duchatelet 
and Martinet (1825), in the arachnoid. In this country and America, 
we have had valuable essays and monographs by J. Clarke, Monro, 
Duncan, Yates, Mills, D. Davis, Burnett, Griffiths, J. R. Bennett, H. 
Smith, &c. &c. ; and more or less space devoted to its consideration in 
the works of Underwood (late editions), Dewees, Burns, Maunsell and 
Evanson, Eberle, Stewart, Condie, Coley, and Hood. The recent com- 
munications to the. different periodicals will be found in Braithwaite or 
Banking's Retrospect, and to which I shall hereafter refer. 

More recently great light has been thrown upon the pathology of 
the disease by the valuable essays of Guersent, 1 Papavoine, 2 Fabre 
and Constant, Gherard, 3 Rufz, 4 Piet, 5 Green, 6 Schweninger, 7 &c, who 
have demonstrated the existence of tuberculous meningitis. 

Dr. J. R. Bennett, in his excellent treatise, gives the following 
statistics : Of 1,000,000 of each sex, the annual mortality by hydro- 

' Diet, de Me"d., p. 392. 2 Journ. Hebdom., vol. vi. p. 113, 1830. 

3 American Journal of Medical Science, April, 1834. 

4 Thesis, 1835. 5 Thesis, 1836. . 6 Lancet. 
7 Ubsr Tuberculose als die gewohnlichste Ursache der Hydrocephalus acutus. 



136 ' ACUTE HYDROCEPHALUS. 

cepalus, in 1837. was 562 males and 460 females ; in 1838 it was 574 
males, and 450 females; in 1839 it was 571 males, and 439 females. 
In Berlin, in the year 1833, the deaths below 15 were 4,009, of which 
196 were from cerebral inflammation and hydrocephalus. In 1835, the 
deaths below 15 were 3,477, of which 257 were from acute hydroce- 
phalus. 

Coindet states that on an average 21 children die annually in Geneva 
of hydrocephalus, out of a population of 22,000. 

Bouvier estimates that in Paris 1,000 children are attacked annually, 
of whom 750 die. 

Hasse considers that from 32,000 to 36,000 children die annually 
from this disease in the Prussian States, and 100,000 throughout 
Germany. 

Dr. Alison states that of 201 deaths below the age of 15, at Edin^ 
burgh Newtown Dispensary, 40 died of hydrocephalus ; of 1862 cases, 
under 7 years, at the Marylebone Dispensary, Dr. Boyd says that 67 
were inflammation of the brain or membranes. At the Rains Institute 
for children, of 56 death 9 were from this disease. Of 62 deaths at 
the Bonn Chirgon, 12 were from this disease. 

169. After this brief historical notice, I shall endeavor to sketch 
some of the various phases or forms of the disease sufficiently distinct 
to merit especial mention, and having corresponding pathological con- 
ditions. The first corresponds to the acute hydrocephalus of Golis 
and others, and to the " meningite simple aigue" of Barrier and Rilliet 
and Barthez. It is not the most common, but very far from being rare. 

The different stages into which authors have divided hydrocephalus 
are not always to be clearly distinguished in this form. Conradi and 
Bush made two stages ; Whytt, Cheyne, Tissot, Vanhoven, Baader, 
Plenck, Sprengel, &c, three; Golis four stages : but most frequently 
but two stages will be remarked, that of excitement and effusion. 

170. In some cases a formative period may be observed, during 
which the child loses his spirits and cheerfulness, exhibits a distaste for 
his usual amusements and toys ; the eye has lost some of its lustre, the 
face is somewhat collapsed and pale, and there is a kind of creeping or 
chilliness over the body. The pulse is uncertain — sometimes quick, 
perhaps irregular, in other cases but little altered from its natural state. 

In most cases, however, the development of the disease is sudden, 
and marked by high fever, thirst, heat of skin generally, and particu- 
larly of the head, sometimes, as I have seen more than once, by a 
convulsion. 1 The child complains of severe pain in the head, if old 
enough to express its sensations; and if too young, we find it clasping 
its head ; or constantly raising its hand to that part ; unable to support 
the weight and suffering, it seeks to rest it upon something, rolling it 
about incessantly; or lying still, heavy, and dull, with an occasional 
cry of pain. 

In some cases the eyes have a heavy, muddy expression; more fre- 
quently they are bright and restless, moving quickly from one object 
to another, and the conjunctiva more or less injected. There is a 

1 Dr. John Clarke's Comment, on Diseases of Children, p. ISO, 188Q. 



ACUTE HYDKOCEPHALUS. 137 

peculiar stare, a wide opening of the eyes, so that the white is visible 
all round the iris, which I have found very characteristic of the com- 
mencement of meningitis. 

The infant is generally very wakeful, or sleeps restlessly, drowsy, 
but waking up suddenly, crying or screaming as if from fright ; if it 
sleep continuously, we may observe frequent startings and twitchings 
of the limbs. 

When awake, it is evidently oppressed, sighing, agitated, and utter- 
ing a cross, whining cry; complaining, if old enough, of pains in 
different parts of the body, about the neck, shoulders, or stomach. 

Dr. Mills mentions an irritative cough in the first stage. 1 Alibert 
adds to this an extreme difficulty of respiration, which he considers to 
indicate the commencement of compression. Dr. H. Smith notices this 
cough as occurring in all the stages ; 2 and I saw this difficulty of respi- 
ration precede every other symptom in one of my own children attack- 
ed by the disease. It was remarkable, too, that the difficulty was in 
expiration, not in inspiration. 

The stomach almost immediately sympathizes with the cerebral dis- 
turbance ; there is complete loss of appetite, and in almost every case 
vomiting, sometimes concurrently, in others alternating with the head- 
ache. The tongue is white and loaded, the bowels generally constipated, 
and occasionally most obstinate ; when they are free the stools are 
peculiar, greenish, tenacious, glairy, and fetid. The urine is frequently 
scanty and high-colored or cloudy. 

171. If not at the beginning, yet before the disease has lasted long, 
a convulsion occurs, complete or partial, with only a temporary loss of 
consciousness. Generally speaking, it is not repeated until a later 
period of the disease, but in some severe cases I have known them to 
recur at short intervals. By this it may often be distinguished from 
the convulsions ushering in the eruptive fevers. 

Thus far the disease advances with different degrees of rapidity in 
different individuals, nay, in some cases, as Golis has remarked, there 
is an occasional remission, as if the child were about to recover, after 
which the symptoms return with greater violence. 

The fever rapidly becomes intense, with occasional intermissions, the 
heat of head is great, the headache is severe, with delirium, generally 
moderate, but in many cases with loud outcries, especially, as Parent- 
Duchatelet and Martinet have remarked, when the convexity of the 
arachnoid is principally affected ; 3 the head is declared to be the seat 
of the suffering, either by words or gestures ; and the face is pale and 
livid, or with a circumscribed hectic flush on one or both cheeks. The 
eyes are generally bright but sunk, the pupils contracted, and painfully 
sensitive to light, as the ears are to sound, and the whole expression 
of the countenance is not to be mistaken. The pulse is quick at 
first, then occasionally irregular, and at last intermitting ; but these 
changes are by no means so regular as in some of the other varieties. 
The respiration is at first hurried, then unequal, sometimes slow and 

1 Transactions of the Association of the College of Physicians in Ireland, vol. v. p. 438. 

2 On Hydrocephalus, p. 12. 3 De 1' Arachnitis, p. 207. 



138 ACUTE HYDROCEPHALUS. 

oppressed, and ultimately irregular, a few rapid respirations being fol- 
lowed by an interval of rest; the accordance between the pulse and the 
respiration is no longer observed. 

The vomiting in most cases continues, and generally the constipa- 
tion increases. The child is restless and uneasy, seldom lying still, 
and awaking from sleep with loud cries, or when asleep disturbed by 
startings and twjtehings. 

172. There is a sign which has been recorded by some American phy- 
sicians, which I ought to mention here, although I can give no opinion 
as to its precise value. I allude to the information derived from cere- 
bral auscultation. Dr. Fisher, of Boston, was the first to apply auscul- 
tation to the brain, and he published a valuable paper in the American 
Medical Journal. 1 He has since been followed by Dr. Whitney, 2 who 
certainly deserves great credit for the care and labor he has bestowed 
upon the subject. He describes four sounds heard in the brain in cer- 
tain diseases: 1. The cephalic bellows sound; 2. Cerebral cegophony; 
3. Fremissement cataire, and 4. The cooing sound. 

The first, or bellows sound, is heard in "cerebral congestion, acute 
cerebral inflammation, hydrocephalus, compression of the brain, scirrhous 
induration with softening, ossification of the arteries of the brain, and 
the hydrocephaloid disease." This is the only sound with which we 
have to do, and its value is, of course, diminished by the extremely dif- 
ferent diseases in which it is heard, and occasionally by the difficulty of 
detecting it. Still it is a subject worthy of minute attention, and may 
ultimately lend important aid to the diagnosis. 

173. As the disease advances, the symptoms gradually change from 
those of excitement to those consequent upon effusion or pressure, and 
earlier in those cases where the sutures and fontanelles are closed than 
in those where they are incomplete. 3 The headache is less complained 
of, although the head is still rolled about uneasily, or retracted ; the de- 
lirium subsides, or occurs occasionally; the sensibility of the eye is gra- 
dually lost, and the pupil is generally dilated, and it is evident the child 
can no longer see ; the eye is rolled about, turned upward, or squinting 
takes place; the hearing may for a time appear acute, but at length it 
diminishes, and the infant appears unconscious of sound ; the sense of 
touch remains longer than any other, and at a period of apparent in- 
sensibility I have noticed the child uneasy at being touched or moved. 
Dr. Hennis Green has noticed a temporary but firm contraction of the 
eyelid, which for a time prevents our exposing the eyeball. 

When the effusion (or pressure) is moderate, the convulsions increase 
in frequency, and sometimes in strength; or perhaps there may be con- 
vulsions of one side of the body, and paralysis of the other; when the 
effusion is rapid and excessive, there is often neither convulsion nor para- 
lysis, but coma and rapid sinking. And a new symptom is developed 
about this time, which adds much to the distress of the mother. I allude 
to the sharp, piercing scream of agony which the child utters from time 
to time, and which, I am sure, is the result of pressure upon some par- 

1 March, 1838. 2 American Medical Journal, October, 1843, p. 282. 

3 Dr. John Clarke, Commentai-ies on Diseases of Children, p. 130. 



ACUTE HYDROCEPHALUS. 139 

ticular portion of the brain, and not of pain, as the face at the time is 
not expressive of suffering. This peculiar hydrocephalic scream, which 
occurs in no other disease, and not in every case of this, has been 
noticed by almost all writers, but they differ as to the time when it ap- 
pears. Some, as Stewart and Conclie, place it during the inflammatory 
stage, others at a more advanced period, at the commencement or after 
the occurrence of effusion. My own experience confirms the latter view. 

174. During the intervals of the convulsions, consciousness and sensi- 
bility diminish until they are finally lost. Sometimes local spasms occur ; 
I have seen well-marked spasm of the glottis and crowing inspiration. 
The child now lies quiet, occasionally moving the head, or throwing about 
an arm or leg unconsciously; the eyes are open or only half closed, and 
acquire a glazed appearance, with mucus at the corners of the eyelids ; 
the face is pallid, sometimes waxlike, without expression; sometimes 
sunken and anxious, as representing the last conscious feeling. The 
vomiting rarely continues; the bowels are sometimes evacuated uncon- 
sciously, generally confined ; the urine may accumulate or be passed at 
long intervals, and the belly is sunk, concave. The attack terminates 
by a convulsion, or in coma. 

The duration of this form of the disease varies from thirty-six hours 
to ten or twelve days, rarely so much as the latter; it is much more 
rapid than most of the other varieties of meningitis. 

175. II. Dr. Monro has described a variety of the disease, which he 
calls "the most acute species of hydrocephalus," and which differs from 
the foregoing, especially in its commencement : "It begins," says the 
professor, "like the croup. The child awakes in the night, in a state 
of extreme agitation, and much flushed, and with a quick pulse; he is 
hoarse, and the sound of his voice, when he inspires, is similar to that 
in croup; the sound seems to come from a brazen tube which is con- 
tracted at a certain part." 1 This croupy breathing, in a case he relates, 
was changed for asthmatic respiration, and the little patient gradually 
gave evidence of cerebral disease — high fever, quick pulse, partial con- 
vulsions, dyspnoea, squinting, and insensibility. On dissection, besides 
serum in the ventricles and spinal canal, and gelatinous effusion on the 
upper surface of the brain, "the eighth pair of nerves was of a deep, 
uniform red color along its whole tract, as far as its branches going to 
the lungs." 2 Dr. Monro believes that the peculiarity of this case de- 
pended upon the state of the eighth pair, as he has found an analogous 
condition in patients affected in the same way. Professor Burns has 
noticed a similar deviation from the ordinary form of hydrocephalus, 
and attributes it to the same cause. It is very rapid in its progress, and 
proves fatal in three, four, or five days. 

176. in. The next phase or form of the disease is much more frequent 
than the first ; it is more deliberate in its commencement and progress, 
though probably not less fatal. The stages, too, are much more marked, 
although the irregularities are so frequent that any arrangement based 
upon them has but comparatively little value. 

The child in this case usually exhibits evidences of deranged health 

1 On the Morbid Anatomy of the Brain, p. 70. 2 Ibid. 



140 ACUTE HYDROCEPHALUS. 

some time before the characteristic symptoms appear. The appetite 
may have been lost ; the tongue is generally whitish, often loaded ; 
the bowels relaxed or constipated, with erratic pains in different regions. 
Occasionally, there is some complaint of headache, a crick in the neck, 
or the child in walking is observed to be more feeble on one leg than 
the other, or to drag one leg. These symptoms may excite little atten- 
tion at first ; but they will be found to be accompanied with disturbed 
temper, indifference or irritability, languor, pale countenance, occasional 
chills, and other indications of ill health. 

In cases where hydrocephalus is secondary to organic diseases of the 
lungs or intestinal canal, the symptoms of these diseases will mask those 
of the beginning of the former until their full development. 

177. In ordinary cases, Dr. Golis thus states the symptoms of tur- 
gescence, or of the first stage: "Indifference succeeding to increased 
sensibility and irritability ; a constipated state after habitual looseness 
or diarrhoea ; a scanty, unusually yellow urine, with or without sedi- 
ment; dryness of the skin, which previously, on the slightest exercise, 
even on eating and drinking, and particularly during sleep, perspired 
profusely; sleep without medicine often suddenly occurring in restless 
children ; remarkable gravity and earnestness, which had never been 
previously noticed. These, taken together with the symptoms, are the 
signs by which the turgescence of hydrocephalus may with great justice 
be suspected." 1 

In the majority of cases, the child complains of headache, or, if an 
infant, gives signs of it by putting its hands to its head, rolling it 
uneasily about, and being unable or unwilling to support it. To this 
succeeds vomiting of ingesta, and of bilious or greenish matter ; the 
child becomes dull and heavy, complaining of weariness, disliking the 
light, and sensitive to noise ; often in the dark seeing flashes of light, 
and having the pupils contracted, giving a sharp expression to the eye. 

As I have remarked, the tongue is white and loaded, the bowels 
sometimes free, but often confined ; the stools are clay-colored at first, 
but afterwards of a green color, like chopped spinach, and of a gelati- 
nous consistence, or in some cases resembling tar, and with a peculiar 
smell, compared by Dr. Cheyne to the " smell of the breath in the 
beginning of some of the exanthemata." The child sometimes com- 
plains of pain in the bowels. 

The pulse varies a good deal ; in some cases, it remains long unal- 
tered, in others it is permanently quick, in others sometimes slow and 
sometimes quick. Dr. Whytt states, as I have already mentioned, that 
it is quick in the first stage, irregular and quick in the second, and 
intermitting in the third; but Dr. Cheyne seldom observed this regular 
division. In some cases, no doubt, it exists ; in many, it is certainly 
absent. 

178. Thus the disease may go on for some days, without any very 
marked change, but by degrees we may perceive the child getting 
worse. Febrile paroxysms are observed, with heat of skin, thirst, 
quicker pulse, rapid respiration, and a bad smell from the breath. 

1 On Water in the Head, p. 15. 



ACUTE HYDROCEPHALUS. 141 

The countenance becomes altered, thin, and pale, with a peculiar 
expression, as Sprengel has observed; in some cases, it is oedematous. 
Portenschlag remarks that the glance, the features and complexion, the 
voice, the movements, the actions and sentiments of patients in acute 
hydrocephalus, if they have been known to the physician before the 
commencement of the disease, are very different to what he remembers 
in health. 

179. The headache and heat of head may continue or diminish; and 
there may, perhaps, be some delirium, but it is not so loud or violent 
as in the first species. The vomiting continues, especially in the upright 
position ; the bowels are generally torpid, although we see occasionally 
an attack of bilious purging; the region of the stomach and liver is 
often tender on pressure; and the belly is concave and not tumid. The 
urine is scanty, and frequently voided, generally with sediment ; some- 
times, as Coindet observed, with a white micaceous sediment. 

The senses, which were morbidly sensitive, and the intellect, which 
may have at first been unusually active, gradually lose their power, and 
the child becomes dull and stupid. He lies more quietly in bed, throw- 
ing his head back, and moving about the legs, and picking his nose and 
ears, or rather thrusting his fingers into his nostrils or ears. He 
becomes greatly emaciated, the skin hangs about his arms and legs, the 
pulse increases in quickness and irregularity, the respiration is more 
interrupted by sighing, and very decided symptoms of pressure show 
themselves in the form of twitchings, starting, screaming, and partial 
or complete convulsions, with insensibility, glazed eye, squinting, &c. 
The conjunctiva frequently becomes highly injected with an unusual 
puriform secretion ; and Dr. Stoben, of Strasburg, has remarked a 
semilunar yellow speck at the lower margin of the cornea without undue 
vascularity, but which became an ulcer if the case were protracted. 
Drs. Cheyne and Golis remarked, in several instances, a temporary 
restoration of intellect before death. 

This condition may continue for some days, with but little variation, 
until at length it is terminated by a convulsion or coma. 

180. The duration of this form of disease is greater than the former. 
Perceval, Fothergill, and Vanhoven say from fourteen to twenty-one 
days; Golis from thirteen to twenty-four days; Dr. Cheyne that it is 
almost always over in three weeks ; Dr. Whytt that it lasts four, five, 
or six weeks. Peter Frank saw a case last six weeks ; Drs. Letl and 
Adelt more than two months. 

This form of meningitis, which corresponds with Dr. Cheyne's first 
species, 1 will, with some little modification, apply to those cases in which 
the meningitis occurs in the course of measles, scarlatina, or infantile 
remittent, or when it is secondary to disease of the bowels or liver. 

In most cases it terminates fatally, but in cases of recovery Dr. 
Cheyne remarked the occurrence of large bilious stools, an increased 
flow of urine, or an abundant perspiration. 

181. IV. Dr. Brockman has described, under the term meningitis en- 
cephalica, a species of local meningitis in which the membranes of the 

1 On Acute Hydrocephalus, p. 2. 



142 ACUTE HYDROCEPHALUS. 

pons Varolii and medulla oblongata are chiefly affected. I quote the 
following description from Dr. Condie's excellent work: "It is some- 
times associated with general disease of the brain ; at others it is uncom- 
plicated. Notwithstanding in its earlier stages it is unattended by any 
serious symptoms, it is an affection fully as dangerous as cerebral 
meningitis. The first stage, or that of simple hypersemia, generally 
continues for one or two days. The child is dull and heavy, and the 
occiput is often hot ; the bowels, however, are regular ; there is no vom- 
iting, no intolerance of light, nor any disturbance of sleep. The general 
dulness of the patient, and vague complaints of some uneasy sensation 
in the head, increase as the inflammatory stage sets in ; the heat of the 
occiput is augmented; the head becomes retracted, as in the ordinary 
cases of acute meningitis; and convulsive twitching of the limbs occur, 
similar to the effects of slight electric shocks, which recur every few 
minutes while the patient is awake, but cease during sleep. The general 
febrile symptoms continue during the third stage; the pulse, however, 
diminishes in frequency and fulness, but does not become eicher irregular 
or intermittent. The general disquietude of the child subsides by de- 
grees into a comatose condition, in which the head becomes still more 
retracted, but unattended with strabismus or any morbid condition of 
the pupil: the peculiar air of stupidity which characterizes hydrocephalic 
patients is wanting. Two pathognomonic symptoms, however, indicate 
the occurrence of the stage of effusion. One of these is deafness, the 
other is difficult articulation and difficulty in moving the tongue, both 
of which occur at the same time, probably from paralysis of the motor 
nerves of the tongue. The deafness and affection of the tongue usually 
occur suddenly; sometimes they are first observed upon the child awak- 
ing from a quiet sleep. They are, according to Dr. Brockman, the 
earliest and most certain indications of the occurrence of effusion. This 
stage continues sometimes for three, sometimes for fourteen days. Its 
termination is in fatal paralysis, the occurrence of which is often pre- 
ceded by various singular nervous phenomena, as sudden pauses in 
the respiration, or equally sudden syncope. In some cases, however, 
the paralysis does not follow, but the anomalous symptoms subside, and 
the patients gradually recover. Until, indeed, the paralytic stage is 
fully established, the recovery of the patient is still possible. 

"In the uncomplicated cases of the disease, upon examination after 
death, the cerebrum in general presents an extremely pallid and anae- 
mic condition, in striking contrast with the cerebellum, the vessels of 
wdiich are turgid with blood, while its substance also is often in a state 
of marked hypersemia. The hyperemia also increases in intensity 
towards the central portions of the encephalon; and the membranes 
covering the pons Varolii and medulla oblongata are found in a most 
decided state of inflammation ; the portion of inflamed membrane is per- 
fectly isolated, and not more, usually, than a square inch in extent; the 
membrane of the cerebellum being entirely free from any indications of 
inflammation. There is ordinarily an effusion of a serous fluid into the 
subarachnoid tissue, sometimes to the extent of several ounces ; occa- 
sionally a gelatinous matter is effused, and in some instances the effu- 
sion is of a purulent character. 



ACUTE HYDROCEPHALUS. 148 

"This form of the disease is most frequently observed in children 
from three to ten years of age, and who had previously enjoyed good 
health. 

"The treatment recommended by Dr. Brockman, in its first two 
stages, is depletion by leeches to the posterior part of the head, cold 
applications to the scalp, and the free administration of calomel, which 
latter may be continued during the stage of effusion. Here, however, it 
becomes necessary to support the strength of the patient ; for this purpose 
ammonia, is directed by Dr. Bockman, but he remarks that in some 
cases the administration of wine may be required. According to his 
experience, powerful counter-irritants, as a large blister, or the actual 
cautery, prove also sometimes beneficial." 1 

182. v. The next form I shall describe is the tubercular meningitis 
of the French authors, upon which so much light has recently been 
thrown. According to Rilliet and Barthez, the progress of the disease 
corresponds pretty accurately with the three stages of Dr. Whytt : the 
first characterized by loss of appetite, paleness, quick pulse, vomiting, 
and headache; the second by a slower but irregular pulse, sleep, de- 
lirium, and outcries; the third, by acceleration of pulse, paralysis of 
eyelids, dilated pupils, convulsions, subsultus, &c. Senn and Guersent 
adopt these three periods: Rufz makes only two, including the two first 
of Whytt in one; and Piet makes none. 

From the researches of late years it would appear that this form 
of the disease is much more frequent than any other. Rufz, Piet, and 
Gerhard scarcely met with two cases of simple meningitis to twenty of 
tubercular; M. Becquerel found one case of simple meningitis in six of 
hydrocephalus, Barrier four in thirty. M. Guersent observes: "From 
the observations I have made at the hospital for many successive years, 
it appears that in children from two to fifteen years the proportion of 
simple meningitis to tubercular is as two to twelve ; after puberty simple 
meningitis becomes more frequent." 2 

183. The disease very generally attacks a child in good health, but 
it may supervene in the course of some other affection, especially those 
of a tubercular or scrofulous character. The most common symptoms 
are headache, attended with vomiting and constipation, and these may 
be the first to attract attention ; but in some cases a series of slighter 
disturbances have been noticed, especially by German writers, as fan- 
tastic desires, caprices, uneasiness, sleepiness, giddiness, uncertain walk, 
quick pulse. Formey speaks of a fine dry eruption of the color of the 
skin, milky urine, crossness, irregular walk, nausea, vomiting, &c. I 
saw one case in which, before cerebral symptoms were very marked, the 
child was greatly distressed by optical delusions, visions of animals 
walking before him or around his bed. Restlessness, staring eyes, or 
semi-rotation of the head are also common, with heat of scalp. 

The appetite is not always immediately lost, nor is the thirst great 
until after the eighth day, although the tongue may be dry at an earlier 
period. 

1 Condie on Diseases of Children, p. 423. ' Diet, de Mel., vol. xix. p. 411. 



144 ACUTE HYDROCEPHALUS. 

The vomiting is sometimes very slight or not persistent, and the 
headache in some few cases is less remarkable. The pulse is generally 
quickened, and the child preserves its intelligence. The strength is 
but slightly depressed. 

As the disease advances, the vomiting continues, or perhaps increases, 
at first of bilious matter or of the food taken ; the pulse becomes irre- 
gular, whether quick or slow; the child is cross, dull, grinds its teeth, 
and has a frightened staring look, evidently distressed by the light. 
Then the respiration becomes unequal and irregular, with sighing or 
yawning. The face is sometimes flushed, at others pale, the eye oscil- 
lating or turning upwards, the expression of the face that of surprise, 
or wonder, or indifference, sometimes utterly smooth and without expres- 
sion, like a wax face. 

184. Now these symptoms may last some time before the more decided 
symptoms of cerebral disease develop themselves. At length, however, 
a degree of agitation is observed, with some incoherence, either persist- 
ent or alternating with intervals of perfect intelligence ; an increase 
of somnolence, or starting, clenching the hands, the thumbs being 
firmly flexed inwards, and the ankles bent, and convulsions or coma. 
The convulsion may be general or confined to one side, the other being 
paralyzed. In some cases the coma comes on very gradually, in others 
suddenly ; the eyes become dull and glazed, the corners of the eyelids 
encrusted, and the nares dry. The bowels, at first constipated, are 
afterwards much relaxed, and the stools green and glairy. Occasion- 
ally the jaws are firmly closed, the trunk rigid, the pupils dilated, or 
one dilated and the other contracted ; sharp cries are occasionally 
uttered ; the eyes squint, either divergent or convergent ; the pulse is 
small, quick and irregular ; the respiration irregular ; the skin is 
covered with cold sweat, the stools and urine are passed involuntarily, 
and the coma is persistent and constant. Shortly before death the face 
becomes red or violet, covered with sweat ; the eyes hollow and filmy ; 
nares dry and crusted ; respiration loud, almost stertorous; pulse smaller 
and weaker, with occasional convulsions, until death closes the scene. 

185. The duration of this form of disease is pretty much as the last. 
Rilliet and Barthez have never seen death before the seventh day, but 
most commonly from the eleventh to the twentieth day; in some cases 
the patients lived sixty and sixty-seven days. 

Of 117 cases collected by Dr. Green, thirty-one died before the 
seventh day ; forty-nine before the fourteenth ; thirty-one before the 
twentieth ; and six after the twentieth. 

Of thirty cases noted by Dr. West, the average duration was twenty 
days and a half ; in one, death took place in five days ; in ten, before 
the fourteenth day ; in eleven, during the third week ; and in three, 
during the fourth week. 1 

186. Although I have given this description of the disease with appa- 
rent precision, I should wish to caution my readers against supposing 
that they will always find the exact series of symptoms here laid down ; 
nothing can be more variable than they are : but, on the other hand, 

1 Lectures in Medical Gazette, August 16, 1847, p. 92. 



ACUTE HYDROCEPHALUS. 145 

there are always sufficient to show that the brain is the part affected, 
even in those cases related by Rush, Mills, and others, in which there 
was neither pain in the head, nausea, dilated pupil, nor strabismus. 

Moreover, it must strike every one that between several of the forms 
here described there is comparatively little difference of symptoms, 
although their succession and intensity, and duration vary a good deal, 
nor do I think that they will be found more unlike in practice. Every 
one who has seen much of this fearful disease must have been struck 
with the general resemblance of all cases, and yet with the infinite 
variations in minute points, so that it is almost impossible, in a general 
description, to include even the majority of cases. This must be my 
apology, if one be needed, for apparently multiplying the forms of the 
disease. I have written partly from my own experience, and partly 
from the works of others, most of which I have carefully consulted. 

187. VI. The last form of the disease which I shall notice has been 
called the water stroke ; wasserschlag, by the Germans ; apoplexia 
hydrocephalica, by Cullen and others ; and is described by Golis, 1 but 
omitted by most writers. It consists in a sudden, almost instantaneous, 
effusion of fluid within the brain, and may occur either idiopathically or 
as the result of obstructed secretion from some other organ, or as a 
secondary affection in the course of some other disease, as smallpox, 
measles, or other, febrile eruptions, or on the sudden stoppage of diar- 
rhoea, dysentery, or profuse perspiration. 

Though there are evidences of inflammation occasionally found on a 
post-mortem examination, the suddenness and rapidity of the disease 
prevent the development of the usual symptoms. Those which are to be 
observed rather correspond to the latter stages of hydrocephalus. The 
child may go to bed in its ordinary state of health, or suffering from 
some other disease, and in the morning it may be found dead from a 
cause which is only detected by a post-mortem examination. Or it may 
suddenly be attacked by a convulsion, followed by paralysis or apparent 
apoplexy, with insensibility, stertorous breathing, dilated or contracted 
pupils, and subsultus, terminating in death after a few hours. 

Almost all, if not all, the patients die, and die too quickly for the 
employment of remedies. 

188. Pathology. — It is very rarely that any pathological change is 
discovered in the bones of the cranium ; in one case, Rilliet and Bar- 
thez found some infiltration beneath the pericranium, and the coronal 
suture contained a small quantity of blood. The head being enlarged, 
the bones are more or less separated, and the sutures more widely apart 
than usual. 

The dura mater is generally injected; sometimes the sinus is filled 
with dark blood or gelatinous clots. The cerebral veins contain dark, 
solid clots. 

189. The arachnoid membrane is frequently injected, either gene- 
rally or partially, 2 and in some parts rendered opaque ; in other cases 

l A Treatise on the Hydrocephalus Acutus, &c, by It. A. Golis, translated by R. 
Gooch, M. D., p. 5. 
2 Piorry, de 1' Irritation Encephalique, p. 28. Eberle on Diseases of Children, p. 379» 

10 



146 ACUTE HYDROCEPHALUS. 

it is smooth and polished, but with the products of inflammation in its 
cavity. Occasionally thick, abundant, and inodorous pus is found, as 
described by Golis, Rilliet and Barthez ; or the more fluid portion being 
absorbed, it may lie close upon the serous tissue, and resemble false 
membrane very much, but it is not smooth, and it breaks up under the 
finger. This disposition may be either general or partial. The most 
common result, however, is effusion of serum. 

The pia mater exhibits similar appearances ; purulent matter, more 
or less fluid, occasionally concrete, and more frequently on its convex 
surface, in five out of six cases at the base, and varying in quantity in 
different places. M. Legendre has observed with the microscope that 
the pus globules are large, round, and transparent, without central 
nucleus. 

The ventricles also often exhibit marks of inflammation ; the lining 
membrane may be vascular and softened, and the fluid contained may 
be discolored or muddy ; occasionally pus, more or less fluid, is found. 
But more frequently the ventricles are distended, with a limpid fluid 
resembling serum, but which differs from serum in the proportion of its 
constituents. Dr. Davis says that it is " a fluid sui generis, and is the 
product exclusively of inflammation of the serous membranes investing 
the brain, and. of the vascular tissues concerned in supplying the ence- 
phalon with blood. This is not blood, nor serum, nor purulent matter, 
nor fibrin, but a fluid already stated sui generis." 1 

Berzelius gives the following analysis : — 

Albumen 1.66 

Matter soluble in alcohol with lactate of soda 2.32 

Chlorides of potassium and sodium . . . 7.09 

Soda 0.28 

Animal matter, insoluble in alcohol . . . 0.26 

Earthy phosphates 0.09 

Water 988.30 

1000.00 

That is, the serum of the blood, diluted with about seven times its 
volume of pure water. 2 

The quantity of this fluid varies. Whytt and Golis state it to be 
from two to three ounces ; Coindet, Bright, and Nasse from one to four 
or six ounces ; Brachet as much as twenty-four ounces ; Dr. Copland 
not more than eight ounces. 

Sometimes, however, the fluid is nearly absent. Parent-Duchatelet 
and Martinet state that in eight cases out of twenty-six there was 
scarcely a trace. Ford and Underwood make a similar observation. 

In some cases the fluid is present with few if any traces of inflamma- 
tion. These cases, however, are comparatively rare. 

190. Occasionally the central portions of the brain are diseased, sof- 
tened, and reduced to a mere pulp ; when the effusion is considerable, 
the brain has a compressed appearance and the convolutions are flat- 
tened. The vessels of the brain are considerably congested. 

According to Laennec, Jadelot, Bricheteau, &c, the substance of the 

1 On Hydrocephalus, Preface, p. 10. 2 Traiti de Chimie, vol. vii. p. 141. 



ACUTE HYDROCEPHALUS. 147 

brain is very firm, and, as it were, hypertrophied, and in these cases the 
effusion is slight. 

It is very probable that in many cases the membranes of the spinal 
marrow may participate in the inflammatory action. In one of M. 
Legendre's cases there was serum containing pus globules underneath 
the arachnoid, and yellow purulent matter in the meshes of the pia 
mater ; and in six out of thirty cases of convulsions M. Billard found 
inflammation of the membranes of both brain and spinal marrow. 1 

191. These post-mortem appearances are more or less common to all 
the forms or varieties of hydrocephalus I have noticed, but others are 
superadded in tubercular meningitis ; there we find a peculiar sticky 
condition of the arachnoid, and in the laminoe of the pia mater a depo- 
sition of tubercular matter at different points of the hemispheres, or at 
the base of the brain. These granulations vary in size, although they 
are generally small, and sometimes opaline or white, and semi-trans- 
parent ; in other cases gray and opaque. In most cases we find also 
secretion of concrete pus, or what appears to be false membrane, on 
some portion (generally the base) of the pia mater, which is thickened 
and greenish or yellowish, friable, and sometimes adherent to the brain. 
The central portions of the brain, the septum lucidum, &c, are also 
generally softened, and occasionally there is tubercular deposition in 
the substance of the brain and in other organs. 

" I found in the water-stroke," says Grolis, "the brain commonly 
firmer than in the acute hydrocephalus ; also the bloodvessels of the 
brain and its membranes less enlarged and less turgid than in the 
latter," and "from two to four or six ounces of turbid fluid." 

192. Morbid changes in other organs are rare in any of the varieties, 
except when the meningeal affection is secondary. In such cases we 
may find inflammation or ulceration of the mucous membrane of the 
stomach and bowels, evidences of follicular enteritis, &c. Dr. Cheyne 
mentions that he found in many cases proofs of increased arterial action 
on the surface of the liver, that it was adherent to the peritoneum, 
enlarged, and studded with tubercles. 

M. Rilliet states that in general meningitis and meningitis of the 
convexity tubercles in the lungs or abdominal organs are never met with, 
but that in meningitis of the base alone they are : and we know that in 
tubucular meningitis they are uncommon in the lungs, &c. 

From this short statement of the morbid appearances discovered on a 
post-mortem examination, we may come to some conclusions as to the 
nature of the disease. With some exceptions, in which we find merely 
a collection of fluid, in each form we find traces of inflammation in the 
membranes of the brain, with its results in the form of serum, or pus, or 
lymph. In a large class of cases, in addition to evidences of inflamma- 
tion of the membranes and certain changes in portions of the brain 
itself, we have a deposition of tubercular matter, but whether the latter 
be the consequence of inflammation seems hardly decided as yet. Mr. 
Trousseau believes it to be so, but Rilliet and Barthez incline to the 
opposite view. M. Bouchut considers it a constitutional affection. I 

1 Mai. des Enfans, p. 604. 



148 ACUTE HYDROCEPHALUS. 

cannot resist the temptation to give the conclusion at which Dr. J. R. 
Bennett has arrived in his excellent work on this subject. " 1. That in 
many instances the disease consists simply in inflammation of the hrain 
and its membranes ; the symptoms and the post-mortem appearances vary- 
ing according as the inflammatory action is seated primarily in the sub- 
stances of the brain or in the meninges, and according as it is more acute 
or chronic ; and that in some of the more acute forms, rapidly termina- 
ting in death, little or no effusion may be found. 2. That in by far the 
largest class of cases, the disease is essentially the result of scrofulous 
action, and may or may not be attended by the signs of inflammation : 
that the most characteristic lesions in these cases are the softening of 
the central parts of the brain and the effusion of serum ; but that menin- 
gitis, chiefly of the base, is a very frequent secondary lesion, and is 
usually of a manifestly strumous character, and that therefore in this the 
largest and most fatal class, acute hydrocephalus is but a modification 
of scrofulous disease. 3. That there are cases, from these symptoms 
hardly to be distinguished from the last class, in which effusion into the 
ventricles is the only morbid appearance to be met with after death ; 
and that in these instances, the essence of the disease appears to consist 
in some alteration in the condition of the nervous matter, probably allied 
to irritation and that they may therefore be said to constitute a purely 
nervous variety of hydrocephalus. 4. That there is a class of cases 
distinct from the above, but closely allied to them, which may generally 
be traced to some source of exhaustion, either direct or indirect, in which 
the post-mortem appearances are generally indistinct and of a trifling 
kind, consisting for the most part of some degree of congestion of the 
large vessels and a little effusion of serum ; and that in some of these 
cases, the effusion has probably resulted from injudicious treatment had 
recourse to with a view to cure an imaginary inflammation : these being 
the cases described by Dr. M. Hall, and others, under the designation 
of hydrocephaloid disease." 1 

198. Causes. — Age appears to have considerable influence in predis- 
posing to the disease, and this we should expect from the susceptibility 
of the brain during its growth. Certainly in these countries it is much 
more frequent during the first six years of life than afterwards. It is 
chiefly during infancy that the first or second forms I have described, 
are seen ; tubercular meningitis occurs both during infancy and up to 
ten or twelve years of age. 

Drs. Perceval and Coindet found it most frequent between the ages 
of two and seven years ; and Dr. Emerson, of Philadelphia, found that, 
out of 1602 cases, 1395 occurred before the fifth year, or between the 
ages of five and ten. Dr. Green found it more frequent between the 
ages of five and seven. 

There is some little difference in the liability of the two sexes ; rather 
more males than females attacked during the first six years, and fully 
as many females, or perhaps more, for some years subsequently. 
Afterwards three times as many men as women are attacked, according 
to Parent-Duchatelet. 

1 On Acute Hydrocephalus, p. 156. 



ACUTE HYDROCEPHALUS. 149 

The disease is more frequent in some countries than in others. Dr. 
Cheyne considers it more frequent in Scotland than in Ireland, and in 
summer than winter. I cannot, of course, say how frequent it may be 
in Scotland, but I have reason to believe it very frequent in this city. 
Dr. Steward mentions that it is a frequent disease in America ; Camper 
and Tissot that it is rare in Holland and Switzerland. 

Guersent states that tubercular meningitis is more common in summer 
or autumn ; Piet that it occurs more frequently in March and July. 
Rilliet and Barthez are doubtful whether the season makes any 
difference. 

194. There can be little doubt that the disease is hereditary, especially 
tubercular meningitis, and we frequently see several children of the 
same family successively cut off by it ; this has been noted by almost all 
writers, Sauvage, Ludwig, Cheyne, Odier, Formey, Gcilis, Bouchut, &c. 
Dr. West mentions that " in sixteen out of twenty cases in which the 
health of the relatives was made the subject of special inquiry, it was 
ascertained that either the father, mother, aunt, or uncle, had died of 
phthisis." 1 

Something also may be attributed to the constitution of the child. 
No doubt children of good constitutions, and in perfect health, may 
be attacked by any form of the disease ; but certainly those of leuco- 
phlegmatic habit, or tainted with scrofula, are especially liable ; and 
where there is any disposition to scrofulous tubercle, it will favor the 
production of tubercular meningitis. In a large proportion of cases Dr. 
Mills found unequivocal appearances of scrofula; and eleven out of twen- 
ty-two cases observed by Dr. Perceval were "decidedly scrofulous." 
It is a common opinion that a certain form of the head predisposes to 
this disease, but I have carefully watched children with large heads and 
prominent foreheads without finding sufficient grounds for the belief. 

195. An attack, described as acute hydrocephalus by Dr. Albert, 2 is 
said to have prevailed as an epidemic from March to May, 1825. 
During this period more than 150 infants were attacked, and twenty- 
eight of them treated by Dr. Albert. The disease commenced by 
shivering; followed by heat, intense headache, vomiting, constipation, 
scanty urine, epigastric tenderness, &c. The child was constantly 
rolling the head about, the sleep was broken by starting and cries, there 
was delirium, oscillation of the eyeballs, and automatic movements of 
the extremities. The face was pale, the tongue white or brown, the 
mouth and nares dry, the conjunctiva injected, and the eyes intolerant 
of light. 

Afterwards the child lay still, unable to support the head, the face 
changed, the eyes sunk and turned upwards, the hand raised to the head, 
respiration labored, with deep sighs, sordes on the tongue and mouth, 
emaciation increasing, and the pulse small and quick generally, but 
occasionally slow. From this state very few recovered. 

I may add that it occurred as an epidemic in 1840, 1841, and 1842, 

1 Lectures in Medical Gazette, July 16, 1847, p. 93. 

2 Hufeland's Journal du Prat. Heilkunde, Aug., 1830. 



150 ACUTE HYDROCEPHALUS. 

among the conscripts at Versailles, Lyons, Metz, Strasburg, Avignon, 
Nantz, and Poitiers. 

More recently it has appeared epidemically in this country, at first 
at Bray, Co. Wicklow, in January, 1846 ; in the South Dublin Work- 
house in the following months ; and in April and May in the Belfast 
Workhouse (as we find from a valuable paper by Dr. Mayne) ; attacking 
chiefly boys under twelve years of age, and proving rapidly fatal, in 
some cases in fifteen hours, in others in forty-eight hours, in the greater 
number in four days, whilst in some it was prolonged a fortnight or 
three weeks. There w T ere no premonitory symptoms ; it sometimes 
commenced by pain in the abdomen, followed by vomiting, and subse- 
quently by purging ; at this time the patients had all the appearance 
of collapse, then followed reaction, fever, quick pulse, rigidity of the 
muscles, those of the neck in particular, with a tetanic expression of 
face. Soon after severe general convulsions occurred, or a semi- 
comatose condition supervened, with grinding of the teeth and crying 
incessantly. Towards the close, this state merged into coma, with the 
pulse slow and labored, failure of power of speech and deglutition, and 
involuntary evacuations. 1 

An epidemic also occurred in Milbury and Sutton, U. S., and has 
been recorded by Dr. Jos. Sargent, of Worcester. 2 Of 16 cases, 
scarcely one recovered. Death took place from the 6th to the 13th day. 
It was not, however, confined to children, and it is remarkable that in 
several cases there occurred petechias over the body. The appearances 
I have described presented themselves on post-mortem examination, 
with the exception of the deposition of tubercular matter. 

196. Among the exciting causes may be enumerated milk that disa- 
grees with the child, mental distress in the mother or nurse, of which 
I have seen several examples, prolonged lactation, 3 indigestible food, 
the sudden suppression of an eruption on the head, retrocession of fe- 
brile eruptions, dentition, exposure to the heat of the sun, fright, anger, 
cold, blows or falls on the head. 

Golis mentions that children born immediately after the bombardment 
of Vienna, in 1809, were shortly seized with convulsions, and died : 
within the cranium were found traces of inflammation, and effusion of 
lymph and serum in the ventricles. 

Sir H. Halford and Dr. Abercrombie mention suppressed secretion of 
the kidneys as one cause. 

197. Lastly, either variety may occur as a secondary disease to some 
other affection. Thus we may observe meningitis in the course of in- 
fantile remittent fever, towards the termination of measles, or scarlatina, 
or hooping-cough ; after a severe bowel complaint (gastro-enteritis, fol- 
licular enteritis, cholera infantum) or diseases of the liver, as stated by 
Harris, Curry, Yates, Thompson, Cheyne, &c. 4 

1 Dublin Quarterly Journal of Medical Science, for August, 1846, p. 95. 

2 American Journal of Medical Science, July, 1849, p. 35. 

3 Observations on the healthy and diseased Condition of the Breast, Milk, &c, by 
Ed. Morton, M. D., p. 24. 

4 Cheyne on Hydrocephalus, p. 49. Piorry de 1'IrritationEncephal., p. 52. Golis, p. 
71. Eberle on Diseases of Children, p. 382. 



ACUTE HYDROCEPHALUS. 151 

It is occasionally, but rarely, connected with bronchitis, 1 pneumonia, 
and phthisis. 

I ought to observe that in these secondary attacks there is some little 
difference in the symptoms : there is generally less headache and fewer 
premonitory symptoms ; the attack seems to come on more suddenly, 
often by convulsions, and the duration is less prolonged. 

198. Diagnosis. — The most characteristic symptoms of the first 
stage, according to Dr. Mills, are, " the peculiar expression of counte- 
nance, indicative of oppression, pain, and despondency ; frequent 
sighing ; a disposition to retirement ; a heat, weight, pain, or heaviness 
of the head, or all these combined; waywardness and fretfulness : a 
low, irregular fever ; frequent nausea or retching ; an irregular state 
of the appetite and bowels, and the continuance of the diarrhoea," not- 
withstanding the remedies. The second stage is marked by " the 
heavy sigh, the deep moan, the wild scream, the preternatural dilatation 
or contraction of the pupils, imperfect or lost vision, delirium, difficult 
deglutition, paralysis of one hand, arm, or leg, and of the sphincters ; 
the head permanently bent back ; a slow, intermitting, or rapid pulse ; 
frequent vomiting, or convulsions." 2 M. Trousseau has pointed out two 
symptoms of importance in the diagnosis of meningitis ; one is a pecu- 
liar suspicious breathing, and the other a redness of the skin produced 
by the slightest friction. The former is very remarkable ; the child 
takes a long breath, and then remains without breathing for an irregular 
period of from ten to fifty seconds. I have repeatedly observed this 
occurrence, although not so constantly as M. Trousseau. The cutaneous 
phenomenon exhibits itself several days before death, and is produced 
even by a slight pressure of the finger : it does not appear to be con- 
nected with febrile action, as it is absent in many children who have 
high fever. There are not many diseases likely to be permanently 
mistaken for meningitis, nor can we easily confound a well-marked case 
of the latter with another disease ; but in their commencement some 
diseases do exhibit somewhat similar symptoms, and some cases of me- 
ningitis terminate like other diseases. 

199. i. In cerebral congestion we have a marked series of head 
symptoms not unlike the commencement of hydrocephalus ; there is 
sleep, stupor, even coma, with agitation of the limbs, or rigidity, some- 
times partial paralysis ; the face sometimes flushed, or unaltered, or 
spasmodically twisted ; the pupils, perhaps, dilated ; pulse quick, &c. 

Now as meningitis may be accompanied with cerebral congestion, it 
is not always easy or possible to draw an accurate distinction at first ; 
but as the disease advances, especially if it be prolonged, we shall find 
considerable difference. In meningitis there is less stupor, coma does 
not come on until late; convulsions generally occur; the respiration and 
pulse are more irregular ; the face has a sunken look ; and the disease 
is more prolonged. 

ir. Erujrtive Fevers. — As these sometimes commence by convulsions 
and headache, with quick pulse, we may for a while be in doubt, but 

1 Mills, Trans, of Association, vol. v. p. 861. 

2 Transactions of Association of College of Physicians in Ireland, vol. v. p. 446. 



152 ACUTE HYDROCEPHALUS. 

there is seldom more than one or two convulsions in such cases, and in 
a short time the occurrence of eruption will decide the question : the 
delay is of no consequence, as the treatment, so far as the head symp- 
toms are concerned, must be similar. 

III. Infantile remittent or gastric fever seldom presents sufficiently 
marked head symptoms, at the beginning, to be mistaken for hydro- 
cephalus, but towards its termination, especially when there is follicular 
ulceration, the aspect of the case is very similar. The stupor and in- 
sensibility, however, are never so complete ; remissions almost always 
occur ; the head is often cool ; the headache is not so acute ; there is 
great emaciation, but not that drawn look about the face, or its peculiar 
expression, or the concave condition of the belly, which is generally 
tumid; and we rarely have convulsions or paralysis, or even the twitch- 
ings, startings, and screams ; moreover, it is rare in children under 
four or five years of age. 

Of course, these observations do not apply to those cases of infantile 
remittent which run on into hydrocephalus. 

IV. Golis considers the difference between hydrocephalus and typhus 
fever to be marked by the shorter duration of the period of turgescence 
in the former, the less frequent pulse in the early period, and its irregu- 
larity in the latter; the marked stages; the greater sensibility of the 
eye and ear; the interrupted respiration; the emaciation, and the fallen 
state of the belly, &c. 

V. The fourth variety, or water-stroke, may very likely be mistaken 
for apoplexy, but the history of the disease, the age of the patient, &c, 
will correct this opinion, unless we choose to regard it as a variety of 
the serous apoplexy of authors, the symptoms being very similar. 

vi. An attempt has been made to distinguish between simple acute 
meningitis and tubercular meningitis, but I confess I do not think this 
easy, except in extreme cases. Certainly those cases of the former 
which commence with high fever, delirium, convulsions, and terminate 
fatally in two or three days, do differ widely from the gradual develop- 
ment and slower progress of the latter ; but these cases are by no means 
the most common, and in the majority of cases the course and symptoms 
are so similar, that unless we have some collateral circumstances to guide 
us (as, for instance, a disposition to tuberculosis in other localities, or a 
strongly marked scrofulous diathesis), I should not feel much confidence 
in a positive diagnosis. 

The principal grounds of distinction laid down by Mr. Rilliet, are: 
1. That tubercular meningitis occurs in delicate, often precocious chil- 
dren, and in those subject to glandular enlargements and chronic erup- 
tions of the skin ; whereas in simple meningitis, the subjects are vigor- 
ous, well developed, and healthy. 2. That the former disease is always 
sporadic. 3. That the child previously pines away, and suffers from 
disorder of the stomach and bowels. 4. That tubercular meningitis 
never commences by convulsions, and that the transition from the first 
to the second stage is insensible, the advent of the latter being marked 
by headache, vomiting, and constipation. 5. That the headache is more 
intense, vomiting not so urgent, constipation obstinate, and fever moderate. 
6. That the progress is slow, and 7. That its duration is more prolonged. 



ACUTE HYDROCEPHALUS. 153 

200. Prognosis. -^Every form of the disease is extremely fatal ; very 
little chance remains for the patient, if the first stage, as we may call 
it, be neglected. Rilliet and Barthez state that they have never seen a 
single case of tubercular meningitis cured, and in this they only confirm 
the testimony of Rufz, Piet, Gerhard, &c. 

201. On the other hand, Henri states that he cured thirty cases, Odier 
four out of six, Golis forty-one, and Formey nearly all to whom he was 
called at an early period of the disease. Guersent admits that tubercu- 
lar meningitis may be cured during the first period, but not one per 
cent, at a more advanced stage ; l nor is Dr. West's opinion more favor- 
able. 2 

Drs. Perceval and Whytt give one case of cure. Dr. Cheyne men- 
tions three cases of cure. M. Piorry relates fourteen cases, nine of 
which recovered. 

Various cases of recovery may be found scattered through the peri- 
odicals, such as those by Thompson, 3 Uwins, 4 Watson, 5 Heinekin, 6 in the 
older journals, and more recently in the pages of the Edinburgh Jour- 
nal, Lancet, Medical Gazette, &c. &c. 

I have no doubt that all, or nearly all, must have been in the early 
stage. The fourth variety, or water-stroke, always ends fatally. 

I have seen a considerable number of cases, and although when symp- 
toms of effusion are present the case is hopeless, yet at an earlier period 
I have succeeded in curing a much larger proportion than one might 
have expected, considering the importance of the organ affected, and 
the severity of the disease. 

202. Terminations. — Some German writers have related cases where 
acute hydrocephalus terminated by a critical discharge. Meissner men- 
tions one case in which epistaxis occurred, and another in which there 
was a copious serous discharge from the eyes, with considerable mitiga- 
tion of the symptoms, and a third who recovered after a similar evacu- 
ation. Tortual observed the discharge of serum from the nose, and 
Riecke from the right ear. Jahn mentions the case of an infant in 
whom effusion had taken place, but who was cured after a discharge from 
the ears and eyes. Nasse, Cheyne, &c, enumerate other critical evacu- 
ations, such as profuse sweating, excessive secretion of urine, eruptions 
on the face, &c. 

203. The favorable signs which give hope of recovery after judicious 
treatment are, the occurrence of tranquil sleep, the diminution of the 
startings, the pulse becoming slower, the eyes more steady and less 
sensitive to light, and the expression of the face more natural and calm. 

On the other hand, the rapid, small pulse ; quick, irregular respira- 
tion; dry, furred tongue; livid face ; injected conjunctiva; glazed eyes ; 
increase of the startings and twitchings ; disturbed sleep ; wakefulness, 
or coma, all announce a fatal termination. 

In some cases, but very rarely, the severe symptoms are mitigated, 
and the disease subsides down into chronic hydrocephalus, as in a case 

1 Diet, de MeU, vol. xix. p. 403. 2 Lectures, Med. Gazette, July 16, 1847. 

3 Lond. Med. Repos., Jan. 1814. 4 Med. and Phys. Journal, Aug. 1816. 

5 Lond. Med. Repository, Feb. 1816. 6 Ibid., Sept. 1819. 



154 ACUTE HYDROCEPHALUS. 

of Dr. Monro's; and probably this may be favored in young infants by 
the distensibility of the cranium, for certainly symptoms of compression 
are more marked in children whose sutures are ossified than in very 
young infants. 

204. Treatment. — Believing, as I do, that hydrocephalus consists 
essentially in inflammation of the membranes of the brain, with or with- 
out deposition of tubercular matter, and agreeing with Dr. Davis, that, 
when attacked early, a considerable proportion of cases may be cured, 
I cannot too strongly express my sense of the importance of early and 
vigorous treatment. I am convinced that many children are lost by the 
usual moderate remedies, who might be saved if more active measures 
were adopted. Let me illustrate what I mean by a case. My friend 
Dr. M'Donnell's child, aged four months, strong and healthy, was sud- 
denly attacked by acute meningitis of the most severe character. Six 
leeches were applied immediately to the forehead, and the bleeding 
stopped ; the convulsions became less frequent, and the fever dimi- 
nished ; in about eight hours six leeches were again applied, and we 
found that the convulsions did not return, but the starting, and crying, 
and restlessness continued ; and consequently after the lapse of six or 
eight hours we repeated the six leeches, i.e., eighteen in twenty-four 
hours, stopping the bleeding as soon as the leeches fell, and from that 
moment all the symptoms rapidly subsided, and the child recovered his 
health in two or three weeks. 

But, of course, one rule will not apply to all cases. Many things 
must be taken into consideration ; first, the constitution of the child ; 
secondly, the cause and character of the disease ; thirdly, whether the 
disease be primary or secondary ; and, lastly, the period of the attack 
at which we are called to the child. These circumstances will neces- 
sarily modify the treatment. You cannot bleed a child of a weak con- 
stitution so extensively as one who is strong and healthy ; nor does the 
disease, when secondary, or in an advanced stage, admit of such active 
treatment. Let us examine the principal remedial agents in use. 

205. Bloodletting. — In all forms of the disease, whatever be the con- 
stitution of the child, whether the disease be primary or secondary, if 
the attack be recent, I believe bloodletting to be necessary, either by 
opening the jugular vein or the vein in the arm, by cupping, or by 
leeching. And the quantity taken should be in most cases larger than 
in other diseases, or even large in proportion to the age of the child. 
Moreover, if the good effect be not produced, and the child be able to 
bear it, it should be repeated three or four times; but, if leeches are 
used, the wounds should not be allowed to bleed after the leeches have 
fallen. 

M. Piorry says: "I believe, then, that we ought to bleed, especially 
during the period of congestion ; that twenty, thirty, forty leeches, or 
even more, should be applied, or that one or more venesections should 
be practised — in a word, that we ought to act promptly and energeti- 
cally." 1 Dr. Mills recommends venesection first, and then leeching. 
Dr. Davis recommends that the first bleeding, if we are called early, 

1 Piorry, de 1' Irritation Encephalique, p. 58. 



ACUTE HYDROCEPHALUS. 155 

should be carried to actual fainting — " not to faintishness, but full 
fainting." 1 It is only right to state that Dr. Rush, of Philadelphia, 
was one of the first, if not the first, to recommend large bleeding in this 
disease. 

But if the child be weak, or if the disease be secondary, the amount 
of bleeding must be less ; and I think it better to produce an effect at 
once than to repeat small bleedings, afte£ which we must depend upon 
remedies to be noticed presently. Dr. Cheyne remarks of such cases 
as those he has described : " In most cases, local bleeding by leeches 
or cupping, or general bloodletting from the external jugular vein or 
temporal artery, according to the state of the pulse and strength of the 
patient, must be practised." "But I am convinced that bloodletting, 
unless in very robust constitutions, is not always to be repeated without 
danger." These cases answer to those I have made the second variety 
(17b) of the disease. In the first variety, Dr. Cheyne approves of 
ample and repeated bloodletting. 

In tubercular meningitis, bloodletting is also necessary, according to 
the age and strength of the patient and the intensity of the disease ; 
but Rilliet and Barthez do not think it should be carried to so great an 
extent as in simple acute meningitis. 

In the more advanced stage of either variety, it is rarely of any use, 
and may perhaps do injury by reducing the strength of the child. 

In the first stage, Dr. Rilliet advises leeching, mercury, purgatives, 
and counter-irritants ; if it be in the second stage, calomel, mercurial 
and iodine ointment, mustard cataplasms, and cold lotions to the head ; 
if in the third stage, cold applications to the head, mercurial or iodine 
frictions, suspension of the calomel if there be diarrhoea, and mustard 
cataplasms. When a child of strumous habit is threatened with menin- 
gitis, or is seized suddenly with some of its symptoms, he prescribes the 
treatment for tuberculization in general, as iodine and ferruginous 
preparations, iodine frictions to the head, cod-liver oil, exercise in the 
open air with the head uncovered, but not exposed to the perpendicular 
rays of the sun. 

206. Cold applications may be employed by means of lint dipped in 
cold lotion, or, the head being wet with an evaporating lotion, a current 
of air may be directed upon the head. This I have found of great 
value and a great comfort to the patient. Or a bladder, or a water- 
tight bag may be partially filled with powdered ice, and allowed, when 
spread out, to rest lightly upon the head. The hair should be removed 
as completely as possible before applying the cold. All writers are 
agreed as to the value of this remedy, which should be employed as 
early as possible, and continued until the symptoms have subsided, or 
nearly so. 

Heine, Formey, Foville, and Piorry recommend affusion with iced 
water ; but to this Piet, Senn, and Charpentier are opposed. 

207. Counter-irritation by means of sinapisms or mustard baths to 
the legs, blisters behind the ears or upon the head, is of great value, 
and ought in all cases to follow the bleeding. In those cases in which 

1 On Acute Hydrocephalus, p. 241. 



156 ACUTE HYDROCEPHALUS. 

the bleeding or its repetition is inadmissible, our main dependence must 
be upon counter-irritation and mercury. 

I think that a repetition of smaller blisters has more effect than one 
large one. I generally commence by blistering the forehead, and, when 
that begins to heal, apply another over part of the top of the head, and 
so by degrees irritate the whole of the scalp. This appears preferable 
to keeping a blister open for any length of time. 

Dr. Cheyne recommends that they should be dressed with mercurial 
ointment, so as to aid in bringing on mercurial action. 

Frictions to the head with tartar emetic are spoken well of by Golis. 

If, when the child is recovering, the head symptoms do not disappear 
completely and satisfactorily, great benefit will be derived from a seton 
of three or four silk threads in the arm, which may be removed when 
the child is perfectly well. 

208. Mercury, we have seen, was successful in one of the first cases 
of cure on record, that published by Dr. Dobson in 1775; and since his 
time it has steadily maintained its ground as one of the most important 
remedies we possess. 1 

In every form of the disease its use may be commenced immediately, 
except in the cases preceded or accompanied by diarrhoea. The bowels 
must be quieted, at least before we can give it internally; but should 
the intestinal irritation persist, we may still use inunction with the oint- 
ment and liniment of mercury. 

It is better to give calomel, or hyd. c. creta, in small doses, pretty 
frequently, than in large ones, as being less likely to disorder the bowels, 
and it may be continued until the mouth is tender ; but it must be re- 
membered that it is not easy to salivate a child, and I have found that 
mercurial diarrhoea is a tolerable proof of the constitution being affected. 

Whytt, Odier, Quin, Wilmer, and others, gave it in doses of two, 
three, or more grains at a time, and continued it for many days, not- 
withstanding any effects on the intestinal canal; but I quite agree with 
the following observations of Golis : " In little children of from one to 
four or five months, a quarter of a grain — in larger, of from six months 
to one or two years, half a grain of calomel — given internally every 
second hour, will be sufficient, until it has produced green slimy stools 
four or six times, but not purging stools, against which Perceval has 
already warned us; or until there occur sharp pains in the belly, which 
infants express by drawing up their legs, and whining, but larger chil- 
dren describe with words." 2 

209. I have already mentioned that if diarrhoea be present it will 
require attention, and not merely on account of the impossibility of 
giving mercury internally whilst it continues, but because of the consti- 
tutional and cerebral irritation which it occasions. And in those cases 
where the bowels are torpid, we must have recourse to purgative medi- 
cines, which benefit by emptying the bowels, and act as derivatives also. 
A brisk mercurial purgative in such cases should be given at once, and 
repeated if necessary. Neither are we to conclude, in all cases of di- 
arrhoea, that purgatives are unnecessary; in many instances there are 

1 Cheyne on Hydrocephalus, p. 41. 2 On Hydrocephalus, p. 111. 



ACUTE HYDROCEPHALUS. 157 

accumulations in the bowels which must be removed before relief can be 
obtained, but in such cases I think it better to quiet the irritation first, 
and then give purgatives. 

So long as the stomach is irritable, enemata must supply the place of 
ordinary purgatives, but they do not sufficiently clear out the bowels. 

210. Dr. Davis strongly recommends the administration of an emetic 
after bloodletting for the purpose of controlling the action of the heart 
and arteries ; he prescribes one-fourth or one-fifth of a grain of tartar 
emetic with five grains of powdered ipecacuanha. 

Laennec had previously found great benefit from tartar emetic, but 
I am not aware that he gave it so as to produce more than nausea. 

I have never tried the effect of emetics, nor do I think it would be 
wise. Vomiting for the time increases cerebral congestion, which would 
be injurious ; and in many cases an emetic would be unnecessary, be- 
cause vomiting is already present, and yet we never find that it does 
good. 

There may however be another reason for giving small doses of tartar 
emetic. If it be combined with the calomel, it has been found to quicken 
the action of the latter and so save time. I am indebted to my friend 
Dr. Aquilla Smith for this suggestion. 

211. Drs. Cheyne and Stoker think very highly of James 's powder in 
full doses at the commencement of the disease, and the former mentions 
a case apparently cured by it. Certainly in combination with calomel 
it seems to act beneficially, but I should be very sorry to depend upon 
it alone. 

212. Digitalis alone or in combination with calomel, has been recom- 
mended by many writers, particularly by Weaver and Eormey. Dr. 
Cheyne found it of great use in two cases; others with whom he had 
tried it were too far advanced in the disease. Golis says that he has 
used it for sixteen years, and in several hundred cases, but without any 
great advantage ; the dose he recommends is one-eighth of a grain of 
the powder with half a grain of calomel every two hours. 

213. Very great difference of opinion exists as to whether opium is 
at all admissible in this disease. Cheyne thinks it useful, joined with 
an aromatic, in correcting bilious vomiting and purging. Golis is en- 
tirely opposed to it. Mills speaks favourably of it combined with the 
calomel. Hood strongly recommends it. 1 No doubt it requires great 
caution because of its effect upon the brain, but I have used it with 
great benefit in the cases commencing with severe diarrhoea, and with- 
out any injurious consequences. 

214. Iodine has been used, and it is said with benefit. Dr. Evan- 
son is favorable to its employment, and Rilliet and others strongly 
recommend it. Dr. Roser tried the hydriodate of potash and recom- 
mends it when other remedies have failed, and even when paralysis has 
occurred. He dissolves a drachm of the hydriodate in half an ounce of 
water, and gives thirty drops of the solution in water every hour. 2 Mr. 
Finder, of Lymiugton, has related three cases of hydrocephalus in the 

1 On the Fatal Diseases of Children, p. 192. 2 Hufeland's Journal, April, 1840. 



158 ACUTE HYDROCEPHALUS. 

advanced stage treated successfully by half a grain of the hydriodate of 
potash every two hours. The only apparent effects of the medicine 
were diuresis and salivation. 1 

So far as they go, these cases are encouraging. I have not seen such 
good effects from its use, hut I certainly think it deserving of a more 
extended trial. 

215. Phosphorus has been strongly recommended by M. Coindet, in 
combination Avith three parts of oil of almonds. It is a very uncertain 
medicine, and one which may do mischief, and will require great care. 

Various antispasmodics, such as valerian, arnica, camphor, musk, and 
castor, have been employed, but very little reliance can be placed upon 
them. 

216. When the symptoms are somewhat mitigated, or the disease is 
prolonged, and assumes a remittent character, Piorry and H. Cloquet 
recommend quinine as having been successful in saving several cases. 
During convalescence it is undoubtedly of great value. 

217. I need hardly add, that all possible sources of irritation must 
be removed as speedily as possible ; if the child be teething, the gums 
must be completely divided all round and across ; and if the attack be 
secondary, our most vigilant efforts must be directed to the mitigation 
or removal of the primary disease. 

If there be the slightest suspicion that the mother's or nurse's milk 
does not agree with the child (when at the breast), we should instantly 
change it, and choose a new and healthy nurse, whose milk is a little 
older than the patient, if diarrhoea be present. The mother may be 
unhealthy, or, if healthy, she may be suffering from distress, which is 
quite sufficient, as I can testify, to cause hydrocephalus. 

218. The diet of the child must be restricted during the first two 
periods, and should consist of little more than milk and water, with 
panada. As the disease advances, we must gradually endeavor to sup- 
port the strength ; and, if the termination be favorable, it will need 
care and caution to give sufficient food without excess. A spoonful of 
chicken broth may then be given two, three, or four times a day, and 
increased as the child can bear it. Wine whey will also be found very 
useful, and ultimately solid food and wine and water, if the child be old 
enough. 

219. But far more important than the diet is it to take measures to 
insure absolute quiet and soothing rest for the excited brain. The room 
should be darkened, the air kept fresh and cool, only the necessary 
attendants admitted, and absolute silence enjoined as far as possible. 
When taken out of the cradle or bed, the infant must lie on the lap or 
in the arms ; and, when moving him or walking about with him, the 
movements should be as gentle and equable as possible. Even when 
recovering, all excitement, noise, and merriment should be avoided as 
much as sharp air after pneumonia. 

220. Thus, in the first and second stages of meningitis, our remedies 
are : bloodletting in proportion to the age, strength, and constitution 

1 Med. Gazette, Sept. 30, 1842. 



ACUTE HYDROCEPHALUS. 159 

of the child, and the intensity of the attack, but in greater proportion 
than in other diseases ; cold applications, counter-irritation, purgatives, 
if the bowels are confined; soothing and astringent medicines, if there 
be diarrhoea ; calomel and James's powder ; digitalis. 

In the third stage, a continuance of the calomel, hydriodate of pot- 
ash, cold applications, iodine frictions, or repeated blistering of the 
head, are nearly all that we can do with any prospect of benefit. 

221. Lastly, most anxious inquiries are made of us by parents who 
have lost one child from hydrocephalus as to the best mode of prevent- 
ing the disease in others. We have no medicine which will do this ; 
but, nevertheless, much may be done by good care and judicious ma- 
nagement. If the child be very young, the mother had better not 
nurse the child. A change of milk will do much towards changing the 
constitution. The bowels should be carefully watched, and any devia- 
tions from health corrected ; the gums should be lanced freely, the 
moment there are any signs of irritation ; and the child should neither 
be exposed to heat nor cold. 

As the child grows older, he should be kept much in the country and 
in the open air, be encouraged in running and jumping, and the ordi- 
nary outdoor amusements of children ; but climbing, and many of the 
exercises of the gymnasium, particularly those which require the head 
to be held down, should be avoided. A good shower-bath, or general 
sponging with cold water, every morning, is an excellent thing. The 
more healthy the skin, and the more developed the muscles, the less 
fear there need be for the brain. 

Again, in children with the least predisposition to the disease, the edu- 
cation should be carried on very cautiously; the attention should only be 
occupied for a short time together, the memory not overburdened, and 
every species of intellectual excitement avoided. Let the brain acquire 
strength before any burden be laid upon it. 

The sensibility should also be moderated, and passion controlled, not 
by indulgence, but by a mixture of reason and authority. The diet 
should be nutritious, but unstimulating, and the bowels should be kept 
in order. 

Should the slightest symptoms show themselves, notwithstanding our 
care, Odier, Quin, and Matthey recommend the application of a blister ; 
and Dr. Sachse succeeded by means of an issue in preserving a child 
whose brothers and sisters had died of the disease. I have great faith 
in the benefit to be derived from an issue (three or four threads are 
enough), from having witnessed the good effects in several cases. 



160 CHRONIC HYDROCEPHALUS. 



CHAPTER VII. 

CHRONIC HYDROCEPHALUS. 

222. The chronic form of hydrocephalus is much more rare than the 
acute, still we meet with the disease occasionally in children of different 
ages, from birth up to puberty. I have already spoken of hydro- 
cephalus as occurring during intra-uterine life, and I may add that 
even of those cases which occur after birth, there is good ground for 
believing that many commenced during intra-uterine life. 

Chronic hydrocephalus may be divided into two species, the congeni- 
tal, including those, the causes of which can be traced back to birth or 
previously, and acquired. 

223. i. Congenital Hydrocephalus. — This may coexist with a head 
less than usual, of the natural size, or of increased volume. Bouchut 
considers the second case more frequent than the first, but Dr. Battersby 
denies this, and states that the first is always congenital. " Most fre- 
quently children with a head of diminished size have at their birth the 
fontanelles closed, and the sutures ossified. Most of these children die 
as soon as they are born, or perish in convulsions a very short time 
after birth. They are absolutely deprived of intellectual faculties, and 
their senses are obliterated. The head of these little ones is constantly 
pointed at its summit, and depressed laterally towards the ears. The 
forehead is also flattened, and the head covered with thick hair. The eyes 
are constantly convulsed, they rotate, and are insensible to the light ; the 
pupil is much dilated, and in some cases the iris has appeared to adhere 
to the cornea. The face, without any expression, is the image of stu- 
pidity. The voracity of these children is great, yet nutrition is badly 
performed ; liquids are swallowed with great difficulty ; they lose their 
breath, and excite fears for their suffocation. The stools and urine are 
discharged involuntarily. The voice is a feeble and hoarse sound. The 
feet are crossed immovably ; the thighs are flexed on the abdomen. 
These unfortunates can never stand nor walk. Their extremities are 
cold. They appear to have only a vegetative existence ; they never 
exhibit a spark of reason, and are one of the saddest pictures of hu- 
manity." 1 To this form of disease, Cruveilhier proposes to apply the 
term microcephalus, and he divides it into three varieties: 1. With 
atrophy of the brain. 2. With serous effusion into the cavity of the 
cranium ; and 3. Where there is atonic atrophy and effusion. 2 

1 Battersby's Essay, Ed. Med. and Surg. Journal, Jan. 1851. In rewriting this chapter, 
I have availed myself very freely of my friend, Dr. Battersby's able and learned papers, 
iu which are collected nearly, if not all the facts on this subject, and in which the differ- 
ent points are investigated with great care and acuteness. 

2 Anat. Path., Livr. 3, PI. 4. 



CHRONIC HYDROCEPHALUS. 161 

Cases of hydrocephalus with the head of the natural size or unusually 
small are related by Mr. Ward 1 and Dr. Battersby. 

Hydrocephalus with an enlarged head is undoubtedly the most fre- 
quent ; there may be no evidence of the disease at birth, or so slight 
that it excites no attention, and yet the morbid cause may be, or may 
have been some time at work, and the case strictly one of congenital 
hydrocephalus. 2 

Barrier remarks that although at birth the head may not be unusually 
large, yet as the functions of innervation are too feebly developed to 
suffer much disturbance from a slight cause, there may be more fluid 
than usual within the cranium without our being able to detect it. 3 

224. II. Acquired chronic hydrocephalus, as Barrier observes, is some- 
times, though rarely essential, idiopathic, and analogous to other essential 
dropsies ; at other times it is symptomatic of another disease. The 
most common disease giving rise to it is tubercle in the brain, or a can- 
cerous or other tumor. Such cases are mentioned in the works of 
Bonetus, Morgagni, Lieutaud, and Portal. Lallemand, John Hunter, 
Danz, and Constant, mention tumors of the cerebellum with fluid in 
the ventricles ; but they do not state whether there was compression 
of the straight sinus. Magendie attributes hydrocephalus, among other 
causes, to an obstruction to the flow of the cerebro-spinal fluid through 
the ventricles, and has given cases of hydrocephalus with compression of 
the fourth ventricle by a tubercle of the cerebellum ; by an aqueous 
tumor upon the aqueduct of Sylvius, the valve of Vieussens, and the 
fourth ventricle, and also by compression made upon the mesocephalon 
and the fourth ventricle by an exostosis of the basilar portion of the 
occipital bone. He also alludes to cases of hydrocephalus with com- 
pression of the fourth ventricle by a fibrous tumor, developed in the 
valve of Vieussens, or by tumors of different kinds seated in the annular 
protuberance. 4 

Barrier gives three cases of hydrocephalus from compression of the 
straight sinus, in children aged 3, 4J, and 5 years. He conceives 
that the anatomical conditions of this form of hydrocephalus are, 1. 
That the tuberculous tumor should occupy the middle lobe of the cere- 
bellum. 2. That it should make superiorly a projection sufficiently 
considerable to throw up the tentorium cerebelli, and to compress the 
straight sinus. 5 

Rilliet and Barthez agree with M. Barrier that compression of the 
vense galense, or straight sinus, whether by a tumor in the neighborhood 
or by an obstruction in the cavity of the sinus, or by its obliteration, 
as related by Tonnelle, 6 is the most frequent cause. 

Dr. Whytt relates a case in which a scirrhous tumor, occupying the 
situation of the pituitary gland, by compressing the neighboring veins, 
gave rise to effusion. 

225. Hemorrhage into the arachnoid very often resembles hydroce- 
phalus, either, as Rilliet and Barthez suppose, by a separation of the 

1 Lond. Med. Gaz., March 27, 1846. 2 Bouchut, Mai. du Nouveaux Nes, p. 450. 

3 Mai. de l'Enfance, vol. ii. p. 585. 4 Sur le Fluide Cephalorachidienne, p. 74. 

5 Mai. de l'Enfance, vol. ii. pp. 594, 603. 6 Mai. des Enfans, vol. ii. p. 32 
11 



162 CHRONIC HYDROCEPHALUS. 

serum and crassamentum, or by exciting inflammation and effusion, 
according to Breschet and Legendre. 1 

226. Lastly, it would appear that chronic hydrocephalus may be a 
sequence of the acute meningitis already described. 2 In such a case 
the symptoms subside in a great degree, but do not disappear; the fever 
diminishes, the headache is less acute and only occasional, the pulse 
may become less frequent, but the symptoms of cerebral disturbance and 
oppression continue, although in a mitigated form. 

Dr. West observes that, even where no false membrane is found within 
the ventricles, their lining often presents other evidence, besides mere 
thickening, of its having been the seat of inflammation. Sometimes it 
is very hard and granular, presenting an appearance closely resembling 
shagreen, and communicating a very perceptible sense of roughness to 
the finger. " These and other similar alterations of the lining of the 
ventricles, afford conclusive evidence of the inflammatory origin of most 
cases of chronic internal hydrocephalus." 

M. Billard thinks that chronic hydrocephalus succeeds almost con- 
stantly to acute meningitis, and I have seen one case at least which 
seems to confirm this view. 

At the same time I must not conceal that many authors — Barrier, 
Rilliet and Barthez, Breschet and Battersby — are opposed to this opinion. 

227. Symiotoms. — I have already quoted a description of symptoms 
in those cases in which the head is smaller than usual. 

In other cases of congenital hydrocephalus, the symptoms at first may 
not be very striking, some want of muscular power or feebleness of one 
side seems less perfect than usual, rather less intelligence than ordinary, 
and no attempt at articulate speech, will probably be all the phenomena 
to be observed. 

The same may be said of most of the cases of acquired chronic hydro- 
cephalus in the early period and at an early age. If the attack come 
on at a more advanced age, there will be a sort of retrogression of 
development ; the child will lose its muscular power, or the natural exer- 
cise of it, the senses and intellect will be more or less deranged, &c. 

But if the case be one of chronic meningitis, the train of symptoms 
are a good deal changed in character. Dr. Copland thus describes 
them: " Chronic meningitis commonly succeeds to the acute form of the 
disease, but it often presents the chronic characters from the commence- 
ment. There is generally continued headache, with slight somnolency, 
sluggishness and incapacity or want of desire for intellectual exertion, 
moroseness, irritability of temper, sometimes confusion of ideas, embar- 
rassment of speech, and delirium, terminating in confirmed mania or 
idiocy. The motions of the limbs are slow, difficult, or painful, and 
their muscles are subject to involuntary motions and twitchings, and 
sometimes are not under the control of volition, or are altogether para- 
lytic. Vomiting and convulsions are rarely present, excepting in infants, 
where they are often the chief or only signs. In children the peculiar 
knitting of the eyebrows, retraction of the angles of the mouth, whin- 

d Revae M&L, Dec, 1842. 2 Copland's Dictionary, part i. p. 230. 



CHRONIC HYDROCEPHALUS. 163 

ing or peevish cry, stupor, grinding of the teeth, scanty urine, obstinate 
costiveness, and increased heat of the head, are the chief symptoms." 1 

228. At a more advanced stage, the symptoms are common to all the 
varieties of chronic hydrocephalus which commence after birth with 
some modification. The organs of sense are all more or less affected, 
the eyes are turned upwards or downwards, or to one side, and unequally, 
so that the patient squints; the pupils are dilated, and the dilatation 
generally increases with the amount of compression ; the sight is com- 
monly weakened by degrees until it is finally lost, although in some it 
is preserved to the end. The nares become dry and insensible to odors ; 
the hearing, which was delicate at first, is lost by degrees ; the taste is 
generally preserved longer, and in some cases is perfect to the last ; the 
touch is unaltered longer than any other sense, and may even be more 
acute than usual, although in many cases it becomes blunted. 

Dr. Bright observes that sometimes at birth, and sometimes within 
a few weeks after, the sight is lost, though the hearing generally remains 
acute, and as the months pass on, instead of the intellect gradually 
developing itself, the mind is almost stationary and the powers of the 
body are paralyzed. Patients so affected generally lie in bed with the 
body and legs much bent and contracted, and lose the power of straight- 
ening themselves, and some have entirely lost the power of their legs, 
and retain a slight power of their arms. 2 

229. The state of the intellect varies in different patients. Perfect 
idiocy results from congenital hydrocephalus, as in the cases related 
by Schmitt 3 and Battersby ; and this is confirmed by Espinol's experi- 
ence. 4 But in acquired chronic hydrocephalus, as a general rule, after 
effusion has taken place to any extent, we find the intelligence more or 
less affected, excepting perhaps in some of those cases where the head 
rapidly enlarges. After a time, it is evident that the child has not the 
mind of his age; it has become stationary, and then it retrogrades until 
he acquires the look of an idiot, forgetful, scarce understanding what 
is said to him, babbling words without meaning, or at cross purposes, 
neither able to explain his sensations nor his wants, until at last he 
seems sunk in indifference, stupor, or coma. 

This is not always the case, however. Michaelis mentions the case 
of a man, aged twenty-nine, whose head began to enlarge three weeks 
after birth. He entirely lost the use of his limbs, a slight movement 
of the arms alone excepted. He was never able to quit his cradle 
unless assisted by three or four people. As he never made use of his 
feet, they remained extremely small, and looked like those of a boy of 
twelve years, forming an odd contrast with the rest of his body, which 
was as large as that of a full grown person. His appetite and hearing 
were both good. His sight was imperfect, and he squinted. His men- 
tal faculties were not contemptible, though he was generally considered 
an idiot on account of his looking so stupid. His spirits were always 
good, and he was glad to see people. 5 

1 Dictionary of Pract. Med., part 1, p. 280. 2 Reports, vol. ii. part i. p. 424. 

3 Bibliotbeq. German., vol. vi. p. 264. 4 Mai. Mentales, vol. ii. p. 335. 

5 Lond. Med. Communications, vol. i. p. 404. 



164 CHRONIC HYDROCEPHALUS. 

Dr. Monro relates the case of a child whose head at eight years old 
measured two feet four inches in circumference, but whose memory was 
strong and retentive, and who was as lively as children usually are. 
He states, moreover, " that it is incredible how little the powers of the 
mind are impaired by this disorder, considering the great enlargement 
of the ventricles of the brain. I have had opportunities of seeing 
several examples of this form of hydrocephalus, and have watched the 
progress of the symptoms for years, yet I have never met with any one 
instance in which the powers of the mind could be said to be completely 
deranged." 1 

Dr. Spurzheim has described several cases in which the mental powers 
were not impaired ; one in particular, a learned man, " whose head is 
extraordinarily high in the anterior-superior part of the forehead, and 
which, according to its size, must contain from three to four pounds of 
water ; yet this man has extensive knowledge. The only inconvenience 
which results from his peculiar state is that he often falls suddenly 
asleep in the midst of the most interesting conversation, at table, at the 
theatre, and elsewhere." 2 

I have a little child of four or five years old under my care at present, 
who has been the subject of chronic hydrocephalus, apparently follow-, 
ing an acute attack, and whose head measures twenty-three inches in 
circumference, whose intellectual faculties are apparently in a state of 
perfect integrity. 

But, as a general rule, I quite agree with Dr. Watson that " most 
commonly the mental and voluntary functions are maimed and per- 
verted, as may be seen in the cases related by Howship, Solly, Chatto, 
Reil, Craigie, Ecmark, and Ryan, referred to in Dr. Battersby's paper, 
as well as those added by himself. 

230. The most striking feature of the disease is the enlargement of 
the head. In infants, it commences soon, and proceeds rapidly, owing 
to the separation of the sutures; but even when these are ossified, 
enlargement has taken place. The amplification is of the vault of the 
cranium only, the hair remaining nearly unchanged; and it has been 
thus described by Dr. Battersby: "The water of the cranium recedes 
from its centre, and the head augments in volume according as the 
quantity of fluid becomes considerable. The bones of the face neither 
participate in nor contribute anything to this enlargement. They pre- 
serve their natural volume and form. The bones of the cranium con- 
spiring to its enlargement are the frontal, parietal, the superior part of 
the occipital, and a small part of the squamous portion of the temporal 
bones. These bones become expanded, thinned, and membranous. The 
frontal expands, is elevated, and advances forwards over the eyes and 
the face, which looks narrower and shorter. The angle which the 
superior part of the frontal now enlarged forms with its orbital portion 
diminishes, and is effaced almost entirely, so that the eye is driven 
down and concealed by the lower lid, which ascends to the level of the 
centre of the pupil. Camper remarks that this disposition alone would 
suffice to recognize chronic hydrocephalus, even although all the rest of 

1 On Hydrocephalus, p. 138. 2 Monro, Morbid Anat. of the Brain, p. 138. 



CHRONIC HYDROCEPHALUS. 165 

the head were covered. The bones forming the vault of the cranium 
are separated, and the intervals, more or less large, separating them 
are occupied by a fine membrane, through which fluctuation of the 
water inside can be felt distinctly. This separation is very great 
between the parietal bones, especially at the fontanelles. The mem- 
brane filling these spaces is sometimes distended to such a degree as to 
form a very visible longitudinal tumor. On pressing strongly the 
fingers upon these parts of the head, no depression is left, and the 
intervals of the bones yield to the compression like a bladder full of 
water. On gently striking one of these intervals, the liquid can be felt 
at the opposite side. " Resistance is felt everywhere else, that is, in the 
parts naturally ossified." 1 

For a considerable time the face is unaltered, or if anything, it seems 
to shrink, and the aspect of the enormous head with the small face gives a 
very peculiar expression to the child — the fades hydrocephalica, as it has 
been termed : an old, withered, semi-idiotic look. Dr. Monro states 
that in the end the bones of the face are enlarged, and the angles of 
the eyes more distant from each other. 

When the enlargement of the head is great, its weight is inconvenient, 
so that the child has much difficulty in supporting the head upright, and 
in extreme cases, when the muscles of the neck are weakened, it is quite 
unable to do so, and either reclines it on one shoulder or on some arti- 
ficial support. 

231. The power of locomotion is enfeebled in all cases, and in many 
absolutely lost. The limbs are weak and the walk uncertain and trem- 
bling, requiring assistance and support, until, from the atrophy of the 
muscles or want of innervation, the child is unable to walk at all, and 
remains in the recumbent position. 

In other cases the paralysis is observed earlier, even from the begin- 
ning, and as Dr. Bright remarks, the patients lie abed with their legs 
bent under them, or as in Dr. Ryan's case, where the child was nearly 
deprived of the functions of vision, hearing, taste, smell, and touch, and 
entirely of voluntary motion ; and in those of Dr. Battersby's cases. 
In some cases one leg only is affected ; in others, the lower half of the 
body, and occasionally the entire extremities. 

Not unfrequently the child is attacked by general or partial convul- 
sions, and these may immediately be followed by paralysis, which may 
extend to the muscles of organic life, giving rise to difficult deglutition, 
retention of urine, or constipation, or involuntary evacuations. 

The respiration, circulation, and digestion are apparently unaffected 
for a considerable time. Many patients have a good appetite, nay, 
even a voracious one, and digest well, though without any increase of 
flesh. Vomiting, however, is observed occasionally. The pulse, which 
was natural or rather quicker than natural at first, becomes weak and 
small after a time, the heat and moisture of the skin diminish, the 
respiration at length becomes labored, with an access of dyspnoea. 
The appetite also diminishes ; there is little relish for the food taken, 
and emaciation advances rapidly. In short, as M. Barrier has pithily 

1 On Chronic Hydrocephalus, Edin. Med. & Surg. Journal, Jan. 1850. 



166 CHRONIC HYDROCEPHALUS. 

observed, " the patient, deprived of the exercise of the functions of 
volition, is reduced to a vegetative life, which in its turn is gradually 
extinguished. 

I am not aware whether the cephalic bruit exists in chronic as well as 
in acute hydrocephalus. Drs. M. Barthe and Roger could not detect it. 
Rilliet and Barthez heard it in one case resembling chronic hydroce- 
phalus, but on dissection the brain was found to be healthy. I tried in 
two of Dr. Battersby's cases and one of my own, but failed to discover it. 

232. Pathology. — We have already seen how much the head is al- 
tered in size and shape, that the bones are widely separated, feeling as 
if loose underneath the skin, and that a species of secondary tumor is 
formed by the protrusion of the water. 

The bones of the cranium are sometimes of their natural thickness, 
but more frequently they are thin, weak, semi-transparent, resembling 
parchment rather than bone. They are very porous, and the radiating 
fibres around each point of ossification are very visible. Dr. Battersby 
observes " that the first lineaments of the Wormian bones are observed in 
hydrocephalic subjects of a very tender age. Breschet remarked little 
osseous needles in the membranes by which the edges are most generally 
united. These needles are very remarkable in the skull of a hydro- 
cephalic foetus preserved in the Museum of the Rotunda Lying-in Hos- 
pital." 

On the other hand, the bones are sometimes found thicker than natu- 
ral. Ecmark, Malaconne, and Kartell have found them of a thickness 
proportioned to their surface or to the volume of the head. Riedlin says 
he met them twice as thick as natural in a hydrocephalic head of seven- 
teen years. Joder speaks of a child two years old in whom all the 
bones of the vertex had a thickness of nine or ten lines. The cranium 
described by Molyneux was so thick that the physician took the head of 
the patient for that of a giant. Breschet met with a case of hydroce- 
phalus in which the bones of the skull had the thickness natural to a 
well-formed adult, and which were united by solid suture. 

The size of the head varies widely. In some cases it is very great. 
Meckel states that he had seen a foetus of seven months, the transverse 
diameter of whose head was sixteen inches. The head of another foetus 
come to its full time was, at birth, fifteen inches in circumference and 
five inches in height. Another by Willan, at twenty months, was 
twenty-eight inches in circumference and nineteen from ear to ear ; 
one by Freind at two years was twenty-nine inches. A head in the 
Museum of the Rotunda Hospital, Dublin, is stated to have been twenty- 
two inches in circumference when the mother was delivered by the 
crotchet. Wrisberg delivered a Jewess with the crotchet, and the head 
was ten inches long and thirty and a half in circumference. Dr. 
Monro's case, at nine years, was thirty-six and a half inches in cir- 
cumference. The head in Bartholin's case was forty-eight ; in Cruik- 
shank's, at sixteen months, fifty-two inches. 

The quantity of fluid found in the hydrocephalic heads is often very 
considerable. Willan, in a child aged twenty months, found four quarts; 
Ecmark eight pounds, and Duncan eight pounds eight ounces ; Wris- 
berg, in the Jewess's child, nine pounds ; Brittner, twenty pounds; Steg- 



CHRONIC HYDROCEPHALUS. 167 

man, twenty-four pounds ; Cruikshank, twenty-seven pounds ; Sequard, 
thirty-six pounds, and Sichel, fifty pounds. 1 

Breschet's analysis of the serum is as follows : — 

Water 9.900 

Albumen . . 0.015 

Osmazome 0.005 

. Muriate of soda 0.005 

Phosphate of soda 0.005 

Carbonate of soda ....... 0.090 

Other analyses by Marut, Bostock, and Berzelius give nearly the 
same results. The fluid withdrawn by puncture by Dr. Battersby, at 
eight different times, ranged from 1006.5 to 1014 spec, gravity. "Al- 
bumen was always present, but in very variable proportions ; the 
quantity was sometimes very great, as at the second and third punc- 
tures, when it nearly equalled that in the fluid of ascites, forming when 
heated a solid mass like the coagulated white of egg. It sometimes 
amounted to a mere trace, and the specific gravity was influenced by- 
the amount of it present, so that the former became a measure of the 
quantity present. Nearly the same salts were found in all the speci- 
mens, and generally in about the same proportions, viz: a large amount 
of the chlorides of potassium and sodium, small quantities of the sul- 
phate of soda and the phosphate of lime, and a little free alkali, which 
always gave the fluid an alkaline reaction." 2 

According to Breschet 3 the fluid may be contained (a) between the 
dura mater and the cranium ; (b) between the dura mater and the 
arachnoid ; (c) in the cavity of the arachnoid ; (d) in the ventricles, or 
(e) in the laminae of the pia mater. The cases of ventricular hydro- 
cephalus are very much the more common, and in most cases there will 
be some fluid found in the spinal canal. 

A recollection of these different localities will in a great measure en- 
able us to understand the various conditions in which the brain has 
been seen by different observers. Thus the brain is said to have been 
found in a rudimentary state resembling a gland, and of small size, by 
Gall, Breschet, Baron, Billard and others, which would naturally result 
from compression exercised upon it by fluid on its outer surface ; or it 
may be, from extreme distension, assume the appearance of a thin, almost 
membranous bag, as in Dr. Battersby's cases and many others. Ac- 
cording to the amount' of distension will be the thinness of the walls of 
this pouch, and in extreme cases, it will be difficult to distinguish be- 
tween the white and gray matter, or to recognize the central portions 
of the brain at all. Generally we find the corpus callosum raised 
nearly to the skull, the septum lucidum defective or injured, the corpora 
striata flattened, the nerves atrophied or softened, 4 or there may be 
no traces of these parts at all. 5 The substance of the brain may not 
only be unusually diminutive, but it may be softened and more or less 
disorganized. 6 

The membranes in all cases of congenital hydrocephalus exhibit no 

1 Battersby's paper, Ed. Journal, Jan. 1850. 2 Ed. Med. and Surg. Journ., Oct. 1850. 
3 Diet, des Sciences Med., art. Hydrocephale. 4 Boucbut, Mai. des Nouv. N6s, p. 453. 
5 Monro, Morbid Anat. of the Brain, p. 31. 6 Stewart, Dis. of Children, p. 525. 



168 CHRONIC HYDROCEPHALUS. 

morbid alterations ; and even in acquired hydrocephalus, these changes 
are not very frequent. The dura mater is seldom altered, but M. 
Breschet mentions the absence of the falx cerebri. The arachnoid is 
sometimes whiter than usual, and infiltrated with serum. The pia mater 
is excessively thin, but not destroyed. 

On the other hand, some cases occur in which there is evidence of 
inflammation, as in the case described by Dr. West, which I have al- 
ready quoted, where the membranes were thickened and rough with gran- 
ulations, or covered with a layer of false membrane both at the base of 
the brain and in the ventricles. 

233. A question of some interest in pathology still remains, viz: 
What is the proximate or pathological cause of congenital hydroce- 



phal 

After a very careful research and a minute examination of the con- 
dition of the brain in these cases, Dr. Battersby has come to the con- 
clusion that chronic hydrocephalus is always congenital, and that 
congenital hydrocephalus is due to an arrest of development, thus 
confirming the opinion of Meckel. 1 M. Breschet observes, "there is* a 
circumstance to which I shall direct the attention of physicians, and 
which appears to explain the frequency of serous intercranial effusions 
in general, and especially of congenital hydrocephalus. The fine re- 
searches of M. Magendie on the cerebro-spinal fluid leave no doubt of 
the existence of this liquid at all periods of life, intra-uterine and extra- 
uterine, and its abundance as well as its constancy appears to demon- 
strate that this liquid performs important functions. Here, then, is a 
natural hydrocephalus, or one which is united with the regular perform- 
ance of the functions of the brain and spinal cord. The study of 
organic evolutions has caused this fluid to be recognized as more abundant 
at the first period of the formation of the cerebro-spinal nervous centres 
than at any other epoch of life. From the existence of this fluid, from 
its more considerable quantity during the first phases of life, to the 
existence of hydrocephalus, there is but a degree." 2 

Now if we compare the condition of the different parts of the brain, 
as the corpus callosum, fornix, septum lucidum, &c, in the case of con- 
genital hydrocephalus, with the description by Tiedemann, of the brain 
of the foetus at different periods, we shall see sufficient exactness to lead 
to the belief that an arrest of development did take place at a certain 
period, whether in consequence of the increase of the head, or from 
some other cause. 

If, moreover, Dr. Todd's opinion be generally accurate, that " when 
an arrest of development of any portion of the cerebro-spinal axis has 
taken place, the space which ought to be occupied by the organ of im- 
perfect growth is filled with liquid," 3 we have the case pretty well 
proved, and may conclude with Meckel, Breschet, Duncan, and Bat- 
tersby, that " whatever be its remote cause, congenital chronic hydro- 
cephalus depends on an arrest of development of the brain, or, according 
to Mr. Anderson and Dr. Coste, of the proper brainy material." 

1 Anat. Pathologique, vol. i. p. 262. 

2 Diet. deMed., art. Hydroceph. Chronique, p. 511. 

3 Cyclop, of Anat. and Phys., part xxv. p. 642. 



CHRONIC HYDROCEPHALUS. 169 

Differing, as I do, in some degree from Dr. Battersby, in not regard- 
ing every case as congenital, I should not, of course, apply any such 
explanation to those cases caused by tumors or local pressure of any 
kind, or to those still fewer, the result of inflammation. 

234. The duration of the disease varies so much in different cases 
that no general rule can be laid down. Some cases live for a year or 
two, and then die ; others live for twenty or thirty years a sort of vege- 
table life. Those who are attacked by the disease after the sutures are 
ossified, are carried off much more rapidly than others, because of the 
greater pressure upon the brain ; but if the amount is not greater than 
the brain can bear, and if its increase be arrested, then life may be 
prolonged. 

Sooner or later, however, almost all the cases terminate fatally, 1 
either from the pressure, from an attack of acute disease, or from the 
absence of due nervous influence upon the organs necessary to life, and 
the consequent failure of those functions. 

235. Causes. — I have already mentioned the proximate causes of 
this disease and as to exciting causes, such as blows, falls, cold, worms, 
&c, our information upon the subject is so vague that it would be 
unwise to found any definite opinion upon it. 

236. Diagnosis. — The only difficulty in diagnosis which can arise is 
previous to the enlargement of the head, and our judgment must be 
formed by a careful analysis of the functional disturbances already 
noticed, among which M. Breschet regards as most important the 
vacillation of the voluntary muscles, the difficulty of equilibrium, and 
the inclination of the head. 

If there be any fever, the case might at first present some resemblance 
to infantile remittent, but the absence of remissions and the gradual 
increase of cerebral symptoms will clear up the doubt. 

The very rare cases of chronic hydrocephalus where no cranial 
enlargement takes place will be with great difficulty distinguished from 
tumors or tubercles of the brain, inasmuch as the muscular weakness, 
want of equilibrium, headache, and in some cases vomiting, are common 
to both. Probably the age and constitution of the child, and the dura- 
tion of the disease, may throw some light upon the matter, as, for instance, 
in a child exhibiting scrofulous tubercles, in other situations we might 
suspect that the head symptoms proceeded from a similar cause. 

After enlargement has taken place, if the sutures be ossified, it might 
in some cases be hard to distinguish between chronic hydrocephalus and 
hypertrophy of the brain, there being many symptoms in common be- 
tween them : if the sutures be not ossified, the presence of fluid can 
scarcely be mistaken, and in the former case, I should think that the 
history of the disease would be a tolerably safe guide. 

237. Treatment. — The principal internal remedies from which we 
have any hope, and but very little from them, are mercury, sudorifics, 
diuretics, and purgatives, with the occasional abstraction of a small 
quantity of blood, if there be any evidence of congestion or inflam- 
mation such as quicker pulse, heat of scalp, or turgescence. 

1 Barrier, Mai. de l'Enfance, vol. ii. p. 612. 



170 CHRONIC HYDROCEPHALUS. 

Dr. Watson speaks in favorable terms of Dr. Graves' plan in two 
instances. Ten grains of crude mercury, one scruple of manna, and 
five grains of fresh squills are to be rubbed together for one dose, to be 
repeated every eight hours. The first patient, a lad who had been ill 
for two or three years, took the above dose three times a day for 
nearly three weeks, ptyalism being produced. Its effects were great 
prostration of strength and loss of flesh, with gradual relief of all his 
sufferings. It operated profusely by the kidneys. The medicine was 
continued twice a day, and at length once a day, for another fort- 
night, when all the symptoms of the disease had disappeared. The 
boy was greatly emaciated. He was then ordered an ounce and a 
half of Griffith's mixture thrice daily, and soon regained his health and 
strength, and got quite well. The second case, a youth of twelve years 
old, after resisting all other remedies, was treated in the same way, and 
the result was a permanent cure. The strength of the dose must of 
course be modified according to the age and strength of the child. 

I may say indeed that mercury in some form or other, from its 
control over the inflammation of serous surfaces, and from its power of 
stimulating the absorbents, and in combination with squills or digitalis, 
or both, from its diuretic effects, is our sheet anchor in most cases. Dr. 
Reid, Clanny, and others, recommend it to be given in large doses, and 
state that they have found it very useful. I confess from my own 
experience I should prefer moderate or small doses, as producing less 
disturbance. At the same time, we may increase the rapidity of the 
mercurial action by using inunction with strong mercurial ointment, or 
by dressing the blister with it. Mr. Wilson speaks strongly in favor 
of mercurial inunction as a means of reducing the size of the head. 1 

Golis recommends calomel internally, mercurial frictions to the head, 
and slightly irritating baths, generous but not stimulating diet, and fresh 
air when the weather is suitable ; by which means he seems to have 
been very successful. 

M. Barrier mentions that iodine has succeeded in a few cases, 2 and 
from its benefit in scrofulous cases it seems deserving of a trial. Drs. 
Maunsell and Evanson speak favorably of it. 

More recently Dr. Guerond 3 and Mr. Hoskyns have published each 
a case in which iodide of potassium was given with great success. 
Half a grain may be given every four hours to a child two years old. 

238. Counter-irritation by blisters or issues is doubtless of great use, 
and when bleeding is inadmissible it is the best means of reducing the 
chronic inflammation. Almost all writers are agreed upon the employ- 
ment of blisters to the head (after having shaved the scalp), or along the 
spine. 

Dr. Mills recommends the ung. ant. tartar, to the scalp, and that 
by some means a permanent drain should be established on the vertex 
or in its neighborhood. 4 

, 239. Two other external modes of treatment have been proposed, and 
to a certain degree have been successful. 

1 Monro, Morbid Anat. of the Brain, p. 146. 2 Mai. de l'Enfance, vol. ii. p. 614. 

3 American Journal of Med. Science, 1851, Ranking, vol. xiii. p. 330. 

4 Trans, of Association, vol. v. p. 457. 



CHRONIC HYDROCEPHALUS. 171 

I. From an opinion that effusion might be the result of want of firm 
resistance by the unossified cranium, compression has been tried. 
Riverius mentions the case of a boy who was thus cured. 1 Sir Gilbert 
Blane used bandages around the head ; 2 Mr. Barnard straps of adhesive 
plaster ; 3 and M. Engelmann, of Kreusnach, both bandages and plaster. 
Sir G. Blane's case was cured in less than three months. 

In Mr. Barnard's cases considerable benefit was derived, and in 
Engelmann's cases, ten in number, the fluid was absorbed, and the 
patient recovered. 4 

Other successful cases are on record. 5 

M. Jadioux, however, regards it as insufficient and injurious. Mr. 
Hood, of Ayton, tried it, but without success ; the pressure brought on 
convulsions. 

Of course, to produce any good effect, the compression must be 
gradually increased, and continued for a considerable time. M. Trous- 
seau uses strips of diachylon plaster, about one-third of an inch broad, 
and applies them, "1, from each mastoid process to the outer part of 
the orbit of the opposite side; 2, from the hair at the back of the neck, 
along the longitudinal suture, to the root of the nose ; 3, across the 
whole head in such a manner that the different strips shall cross each 
other at the vertex ; 4, a strip is cut long enough to go thrice round 
the head, so as to make a firm and equable pressure. 6 If symptoms of 
compression appear they must be loosened, or if the skin be irritated 
they must be removed. Drs. Watson and West recommend the trial of 
Dr. Arnott's air press, as probably superior for the purpose of com- 
pression to any other means. 

240. ii. Puncture of the cranium and evacuation of the fluid was 
proposed by some of the older surgeons (Severinus and Le Cat, &c), 
and in recent times has been practised by Vose, Rossi, Conquest, and 
many others. 

In the former edition I mentioned that a considerable amount of 
success had attended the operation, but the careful investigation of Dr. 
Battersby has shown that there is reason for believing this to have been 
overestimated. Of 5Q cases included by Dr. West in his list, 16 were 
said to have recovered, but the list of cases, on strict inquiry, appears by 
no means so favorable to the operation. Some were merely relieved, 
others remained the same ; others had not been seen for some time, &c, 
so that, according to Battersby, "the conclusion we are justified in hold- 
ing from an examination of the 16 cases reported by West, is, that not 
more than four of these (Graefe's case and three of Conquest's, which I 
still look upon as doubtful) were cured." Three other cases are re- 
ported as cured by Drs. Whitney, 7 Edward, 8 and Kitsell. 9 

On the other hand, besides the 40 unsuccessful cases in Dr. West's 

1 Obs. Commun., 6. 

2 Lectures on the Structure and Physiology of the Bones, p. 269. 

3 Lancet, No. 137, p. 52. 4 Archives Gen. de Med., June, 1838. 

5 Lancet, No. 841, p. 82. 

6 West's Lectures, Medical Gazette, August 16, 1847, p. 270. 

7 Amer. Journ. of Med. Science, Oct, 1843, p. 303. 

8 Ed. Monthly Journal, p. 398, 1846. 9 Amer. Journal, Jan. 1850, p. 218. 



172 CHRONIC HYDROCEPHALUS. 

list, there are many other failures on record. " Monro states that at 
Liverpool, after Vose's case, several cases were operated on which died. 
Breschet operated several times without success, 2 as did also Dupuytren 
three times. Dr. West has given a fatal case from Fabricius Hildanus. 3 
A like unsuccess attended the cases given by Tulpius, 4 Schenkius, 5 
Ferdinandus, 6 Panarolius, 6 Muraltus, 6 Wepfer, 7 Forestus, 8 Francus, 9 
Schenkser, 10 Zang, n Junker, 12 Sorbait, 12 Petit, 12 Loftie, 13 Froriep, 14 Lee, 15 
Vose, 16 Jeffrey, 17 Dickinson, 18 as also the more recent cases of Wod- 
roofe, 19 Watson, 20 Dendy, 21 Parkman, 22 Whitney, 23 Bellingham, 24 Taylor, 25 
Campbell, 26 Storks, 26 Martin, 2 7 Gotz, 28 Chater, 29 Fergusson, 30 Physick, 31 
Taylor, 32 Pepper, 33 and Battersby. 34 We have already seen that Hol- 
brook, Kilgour, and Fergusson punctured the head without effect, as 
also did Mr. Dendy, five times, whilst Monro and Watzer opened the 
dura mater alone. Spengler and Barruel also appear to have punctured 
the brain, but with what effect I have been unable to learn. An accu- 
rate examination of ancient and modern medical works would very pro- 
bably discover other cases, but the above authorities, along with the 
forty cases in Dr. West's table, give about 100 unsuccessful, against 
seven alleged successful cases, or, in other words, one patient in 14 was 
cured by puncturing the head. But this proportion I do not regard as 
by any means exact, as I have known of the operation having been 
performed in Dublin about ten times unsuccessfully, and I have heard 
of others in the country, in which it was undertaken ineffectually. 
Unfavorable results are seldom recorded." 35 

Now, if we could ascertain that the fluid was external to the brain, 
there might be some hope that in such cases, relief and even cure might 
be effected by letting out the water, but as I do not believe that this is 
possible, and as such cases are extremely rare, I believe we can scarcely 
make an exception in their favor. And with regard to the operation 
in ventricular chronic hydrocephalus the above statements are sufficient 
to condemn it altogether. 

Nay more, even if by it we could evacuate the water, and that no 
more was secreted, the condition of the brain is such, as I witnessed 
myself in Dr. Battersby's case, that there could be no hope of its reco- 

I On Hydrocephalus, p. 147. 2 Diet, des Sciences Me"d , vol. xv. p. 455-6. 
3 Obs. Chir. Cent., 3. obs. 17. 4 Obs. Med., lib. i. p. 47. 

5 Obs. Varios., p. 10. 6 Monro on the Brain, &c, p. 70. 

7 Obs. Med. Pract., pp. 49, 53, 60. 8 Schol. adObserv.,30, lib.viii. Schenck., p. 10. 

9 Schenk., Obs. Med., lib. i. 10 Vallisneri, Opera, vol. i. sect. 5. 

II Darstel. blutig. Operat., bd. ii. 3. aufl. p. 68. 

12 Copland's Diet., vol. i. p. 682. 13 Med. Obs. and Inq., vol. v. p. 121. 

14 Notizen aus dem Geb. der Natur und Heilk., vol. v. No. 102, p. 224. 

15 N. Y. Med. and Phys. Journ., 1828. 16 Med. Chir. Trans., vol. xiv. p. 354. 
17 Lancet, vol. i. p. 617. 1836-7. 18 Ibid., vol. ii. p. 42. 1838-9. 

19 Dub. Med. Journ., vol. xxiii. p. 37. w Library of Med., vol. v. p. 147. 

21 Winslow's Psycholog. Journal, Monograph, p. 11. 

22 Araer. Journal, vol. xvi. p. 299. » Amer. Journal, Oct. 1843, p. 305. 
24 Dub. Med. Press, vol. iv. p. 148. 25 Med. Gazette, Jan. 26th, 1850. 

26 Fergusson's Surgery, p. 491. 21 Mem. de Med. 1835. 

23 (Ester Med. Jahrbuch, June, 1846. 29 Prov. Med. and Surg. Journal, Oct. 1845. 
30 System of Pract. Surgery, p. 491. 3I Med. and Phys. Journ., vol. lviii. p. 44. 

32 Lond. Med. Gaz., Jan. 1850. » Amer. Journ. of Med. Science, Oct.l850,p.552. 
34 Ed. Med. and Surg. Journ., July, 1850. 

33 Essay, Ed. Med. and Surg. Journ., July, 1850. 



HYDRENCEPHALOID. 173 

vering a natural healthy working condition. The operation is, as Mr. 
Fergusson remarks, " attended with considerable danger, not from the 
puncture, which is a very simple matter, nor from the sudden escape of 
a fluid, nor from the wounding either a vessel or the brain, but from the 
inflammation likely to succeed." It is usually performed with a very 
fine trocar, on one side of the sagittal suture, so as to avoid the sinus, 
and pressure should be made as the fluid escapes. 

241. [Hydrbncephaloid. — There is an affection of the brain incident 
to the period of infancy resembling in many of its symptoms the latter 
stages of chronic hydrocephalus, so as very often to be mistaken for it. 
A more grievous error could not be committed, inasmuch as the disease 
to which I allude always originates from another cause, and undoubt- 
edly demands a very different treatment. I refer to the affection which 
has been so ably described by Drs. Marshall Hall and Robert Gooch, 
and which has been designated by the former by the term hydrencepha- 
loid, on account of its symptoms very often presenting a striking simi- 
larity to those which betoken inflammation of the brain. 

My experience has led me to believe that this disease is of frequent 
occurrence, and of so insidious and masked a character as to mislead 
the inexperienced members of the profession, and cause them to resort 
to a treatment calculated to aggravate the disorder ; hence, I have 
deemed it proper to insert a few remarks upon this subject. 

" This affection," says Dr. Marshall Hall, in his admirable essay on 
the subject, " may be divided into two stages ; the first, that of irrita- 
bility; the second, that of torpor. In the former, there seems to be a 
feeble attempt at reaction ; in the latter, the vital powers appear to be 
more prostrate. These two stages resemble in many of their symptoms 
the first and second stages of hydrocephalus respectively. In the first 
stage, the infant becomes irritable, restless, and peevish, the face 
flushed, the surface hot, and the pulse frequent ; there is an undue sen- 
sitiveness of the nerves of feeling, and the little patient starts on being 
touched, or from any sudden noise; there are sighing, moaning, and 
screaming during sleep ; the bowels are generally flatulent and loose, 
and the evacuations disordered. If, through an erroneous notion as to 
the nature of the affection, nourishment and cordials be withheld, or if 
diarrhoea supervene, either spontaneously or from the administration of 
medicine, the exhaustion which ensues is apt to lead to a very different 
train of symptoms. The countenance becomes pale, and the cheeks 
cool or cold ; the eyelids are half closed ; the eyes are unfixed, and 
unattracted by any object placed before them; the pupils unmoved on 
the approach of light; the breathing, from being quick, becomes irregu- 
lar and effected by sighs ; the voice becomes husky, and there is some- 
times a teazing cough ; eventually, if the strength of the little patient 
continue to decline, there is a crepitus in the breathing, the evacua- 
tions are usually green, and the feet cold." 

These symptoms will sometimes supervene in young infants to early 
weaning, especially if they should be subjected to improper food. Drs. 
Marshall Hall and West seem to attribute this condition of spurious 
hydrocephalus to either an enfeebled condition resulting from weaning 
or to an exhausting treatment applied for some previous complaint. I 



174 HYDRENCEPHALOID. 

have seen many cases, however, in which the children affected had had 
no previous illness, and the exhausting treatment had been applied sub- 
sequent to the drowsiness and other characteristic symptoms; and these 
are the cases in which the practitioner is most liable to be deceived. 
The children thus affected have been laboring under acute chlorosis ; 
and I have no doubt that the drowsiness, &c, is accompanied in most 
cases by the distressing headache, throbbing in the head, and noises in 
the ears, which generally accompany this enfeebled condition of the 
system, one which in everyway resembles the "pale-faced" amenor- 
rhoea of puberty or after life. 

I do admit the fact that this disease is very often incident to some 
grave illness, which is very exhausting in itself, or for the treatment of 
which active measures have been necessary ; hence, it is very frequently 
found accompanying the earlier stages of pneumonia, where the sympa- 
thetic disturbance of the brain has caused a powerful treatment to be 
directed to that organ, which has been erroneously considered as pri- 
marily affected. 

We may have this disease originating also in cases where there has 
been congestion of the brain, and where, through over anxiety on the 
part of the practitioner, too powerful or too continued a depletory plan 
of treatment has been adopted. Under such circumstances, the pri- 
mary cerebral symptoms may be alleviated by the remedies ; but in a 
short time the child apparently relapses into the same condition ; there 
is restlessness, jactitation, moaning, flushed cheek, drowsiness, irritable 
stomach, and tympanitic condition of the abdomen. To the unwary, 
these may all seem positive indications for resorting again to the treat- 
ment which was so successful in arresting the same symptoms in the 
commencement. Should these erroneous views be carried out, the little 
patient will sink into a deep coma, and die, not indeed of hydrocepha- 
lus, but rather of pure exhaustion, or from serous effusion, the too fluid 
blood leaking out of the weakened vessels. 

Under all circumstances, therefore, of cerebral irritation, it is essen- 
tial for the medical attendant to inquire into the previous history of the 
patient. Discover whether the food of the child has been of such a 
quantity and quality as to sustain the increasing wants of the growing 
child. Examine whether it has been subjected to any exhausting dis- 
charges calculated to exhaust its nervous system and interfere with its 
nutrition. 

I have met with several cases of pneumonia in which the sympathetic 
disorder of the nervous system had induced so much cerebral disturb- 
ance as to mask the original disorder, all the remedies had been previ- 
ously directed to the brain, and as soon as the true seat of the disease was 
discovered the local depletion adopted for its treatment, superadded to 
that which under a misapprehension had been directed to the brain, 
were too much for the little sufferers to endure, and consequent symp- 
toms of cerebral disorder set in which were still supposed to be those 
of advancing disease. Too much caution cannot be exercised on this 
point, and my own experience leads me to apprehend that many a little 
sufferer is hurried to an untimely grave by the fear of acute hydro- 



HYDRENCEPHALOID. 175 

cephalus, on the part of the physician, whilst in reality the opposite 
condition of things exists. 

As the diagnosis of this affection is obscure, and mistakes easily com- 
mitted which have the most mischievous results, where a doubt crosses 
the mind as to the nature of the case, an expectant plan of treatment 
would be more safe and judicious than any other, the mere abstinence 
from remedies, or a species of masterly inactivity in the case and al- 
lowing nature to act, often affording us a valuable hint as to the indica- 
tions to be pursued. 

When, however, our diagnosis is positively made out, there is no dis- 
ease which admits of more effectual prevention and treatment. 

As soon as the existence of any of the symptoms described is ascer- 
tained, the child should be put on good diet and all exhausting treat- 
ment immediately suspended, and tonics and stimulants should be 
given freely. 

The state of restlessness and irritability, so characteristic of this affec- 
tion, must be alleviated by means of anodynes. I have found it a judi- 
cious plan, as a general rule, to be guided by the state of the pupil ; in 
all cases where it is dilated, I administer sufficient doses of opium, or some 
of its preparations, to overcome this condition of the pupil ; the fluid 
extract of valerian and assafoetida, administered either by the mouth or 
rectum, have also an excellent effect in calming the nervous irritability. 
In administering opiates, a sufficient quantity, proportioned to the age of 
the patient, should be given to calm the excitability and produce sleep ; 
in smaller doses it is apt to excite, and by the want of sleep which it 
produces it may maintain, the very condition which we wish to combat. 

In the stage of coma, we must rouse the system by means of sina- 
pisms applied to the whole cutaneous surface, and by free administration 
of brandy and milk and also enemata of brandy water. In some cases 
of very great excitement, I have had great success with inhalations of 
small quantities of ether ; in one case particularly, where a little girl 
four years old, affected with this disease consequent upon a protracted 
pneumonia, screamed day and night incessantly, after having tried in 
vain anodynes, &c, I had recourse to the inhalation of thirty drops of 
washed ether dropped on a pocket handkerchief. The result was truly 
marvellous ; she fell into a deep refreshing sleep for three hours, and 
her convalescence progressed rapidly from that moment. 

Where tonics are required, I believe that there is no better combina- 
tion than a mixture consisting of the ammonio-citrate of iron and the 
sulphate of quinine. 

There is one point which must never be lost sight of, viz : that no 
kind of depletion must be used either directly by loss of blood or indi- 
rectly by exhausting purges. 

In cases where doubt exists as regards the affection, I have found 
that the employment of anodyne enemata, consisting either of laudanum 
or of the fluid extract of valerian soon produced such effects as to con- 
vince us positively of the form of the disease existing, and to justify us 
in pursuing a supporting and calming plan of treatment.] 



176 INFLAMMATION OF THE BRAIN. 



CHAPTER VIII. 

INFLAMMATION OF THE BRAIN. — ENCEPHALITIS. — INDURATION AND HY- 
PERTROPHY. — SOFTENING. — ABSCESS. 

242. Inflammation of the substance of the brain, as distinguished 
from meningitis, with which it is often partially complicated, is a very 
rare disease of infancy and childhood, and indeed its existence is chiefly 
proved by some of its terminations. And it is consequently difficult to 
separate the symptoms which characterize the period of inflammation 
from those, for example, which mark the occurrence of softening or of 
abscess. On this account the present description should be read in 
connection with the notice I shall presently give of ramollissement, &c. 

It does not appear peculiar to any exact age, but certainly is less 
frequent during infancy than childhood ; nevertheless I saw one case 
of a very young infant, the substance of whose brain exhibited traces 
of inflammation, and was extensively softened. 

243. Symptoms. — The characteristics of encephalitis are much less 
vividly marked than those of meningitis : it is sometimes preceded by 
disordered health for some time, loss of appetite, deranged bowels, oc- 
casional headache ; or it may attack a child suddenly awaking out of 
sleep, trembling and frightened ; or in the daytime by headache, vom- 
iting, confusion, and more or less of stupor ; or it may commence by a 
violent convulsion ; or lastly, some defect of movement, or difficulty 
of speech, increasing to absolute loss of the power of articulation, as 
in M. Durand's case, 1 may be the earliest intimation of serious disease 
of the brain. 

The sensibility in some few cases is increased at the commencement, 
but soon diminished ; the eyes are heavy and the pupils dilated. The 
intellect is generally confused, and in some cases the patient is for a 
time delirious. More commonly, however, there is a degree of stupor 
ending often in insensibility. 

How far inflammation of one hemisphere, or of a portion of one hemi- 
sphere, may interfere with the phrenological functions of the organs 
there situated, and so with the mental manifestations, I am not prepared 
to say. 

244. The convulsion may be repeated, or paralysis of one side (he- 
miplegia) may supervene, even during the early stage ; or the paralysis 
may be partial, and combined with involuntary movements, twitchings, 
or convulsions of other limbs. In some cases the limbs become pow- 
erless, and without muscular tone, so that, when raised and allowed to 
fall, they do so like the limbs of a dead person. 

1 Rilliet and Barthez, vol. i. p. 656. 



INFLAMMATION OF THE BRAIN. 177 

However slight the effect upon the muscular system may be, the 
powers of locomotion are affected ; irregularity and difficulty of walk- 
ing, want of equilibrium, the impossibility of standing, or sometimes of 
sitting, are symptoms commonly observed. Dr. Copland has remarked : 
" When cerebritis is general, these symptoms affect all the limbs simul- 
taneously ; when local, only some of them, according to the seat of the 
inflammation." 1 

Occasionally, but much more rarely, the limbs, or some of them, be- 
come rigid, and much pain is experienced in attempting to straighten 
them. 

245. The expression of the countenance is different from that in 
meningitis, seldom so acute or excited, generally pallid and anxious, 
or calm and pale, unless the muscles of the face be spasmodically 
affected. 

There is rarely much fever, the pulse is pretty quick and small, and 
in some cases is but little changed. 

Respiration is at first rapid and regular, but afterwards irregular and 
interrupted. 

The stomach is very frequently disordered, and vomiting, at least 
occasionally, is present. The bowels may be free or constipated. 

All these symptoms may be present when there is nothing but simple 
inflammation of the brain, nay, the disease running on into stupor and 
coma may end fatally, leaving no other traces in the brain than those 
of inflammation ; but in the majority of cases the disease is not thus 
arrested : it continues longer, new symptoms are developed, indicating 
further disorganization, and the disease terminates either in, 1, indura- 
tion and hypertrophy ; 2, softening ; or, 3, abscess. 

246. A post-mortem examination reveals considerable congestion of 
all the vessels of the brain, especially of the pia mater, and a minute 
vascular condition of the brain generally, or of some part of it. In 
almost all cases, moreover, we find evidences of a more advanced state 
of disease, to which I shall refer by and by. 

247. Causes. — All the causes which act upon the nervous system, as 
enumerated among the causes of meningitis, appear capable of pro- 
ducing encephalitis. There are some local affections which have been 
followed by the latter disease, and which I must not omit to notice. In 
a case quoted in Rilliet and Barthez, the child, aged nine years and a 
half, had shortly before suffered from purulent ophthalmia, by which 
she lost an eye, and it seems probable that this may have had some 
share in the subsequent cerebral attack. 

Other cases are on record, in which inflammation of the brain has 
followed disease of the ear. Dr. Abercrombie mentions a case of in- 
flammation and abscess, which came on in a boy who had been two 
months affected with headache and discharge from the ear ; and others 
have recorded similar cases. 

248. Diagnosis. — I do not know of any symptoms sufficiently pa- 
thognomonic to enable us to pronounce with certainty that the sub- 
stance of the brain alone is affected by simple inflammation. The more 

1 Diet, of Med., Part i. p. 231. 

12 



178 HYPERTEOPHY AND INDURATION OP THE BRAIN. 

rapid loss of voluntary power, the earlier occurrence of paralysis and 
stupor, and the inferior amount of excitement, mark certainly a differ- 
ence between the present disease and meningitis ; but although the 
history of the two diseases varies a good deal, the differences are not 
very characteristic. 

249. Treatment. — However difficult it may be to distinguish between 
this and other cerebral diseases, there can be no doubt in any case that 
the brain is affected, and by an inflammatory disease, so that our plan 
of treatment is pretty clear. 

Abstraction of blood by leeches or venesection is essential at an 
early period of the disease, and the quantity must be regulated by the 
constitution and strength of the patient, and the intensity of the 
disease. Qseteris paribus, however, I do not think that excessive blood- 
letting is so necessary in this disease as in meningitis ; but if the 
symptoms continue unmitigated, the leeching should be repeated. 

Counter-irritation, by iodine frictions or by blisters to the head, 
neck, or behind the ears, will also be necessary, and it will be well to 
dress the blister with mercurial ointment, for our great object should 
also be to bring the system under the influence of mercury. Calomel, 
or the hyd. c. creta;, may be given in moderate doses frequently, 
combined with the pulv. cretee c. opio, if the bowels are too freely 
affected, and continued until either the gums are tender or mercurial 
stools produced. 

If the bowels are constipated, purgatives will be necessary. 

The diet should be mild and unstimulating during the period of in- 
flammation ; it may be increased when other symptoms set in, if the 
child can swallow. 

We shall now proceed to treat of the terminations of encephalitis, 
and first of 



I. HYPERTROPHY AND INDURATION OF THE BRAIN. 

250. I must candidly inform my readers that there appears consi- 
derable doubt in the minds of pathologists as to whether hypertrophy 
and induration are the result of inflammation: the disease is rare, and 
generally obscure, and it is not easy to trace its origin, but, judging 
from analogy of other organs, I am inclined to regard it as the result 
of inflammatory action. Hufeland remarks, that any cause which gives 
rise to congestion of the brain may also cause hypertrophy ; and 
Laennec, who was one of the first to describe the disease, remarks : " It 
has happened to me to see several cases, which I considered internal 
hydrocephalus, but which, on a post-mortem examination, presented but 
a small quantity of water in the ventricles, although the flattened con- 
volutions of the brain proved that this viscus had undergone a degree 
of compression which could only be attributed to excessive size and 
consequently to too active nutrition of the cerebral substance." 1 

The disease has not been long known, and we are indebted for our 

1 Rilliet and Bartkez, Mai. des Enfans, vol. i. p. 654. 



HYPERTROPHY AND INDURATION OF THE BRAIN. 179 

information chiefly to the researches of Scouttetten, Jadelot, Laennec, 
Eouillaud, Andral, Miinchmayer, Papavoine, Sims, Green, Lees, Mauth- 
ner, &c. 

251. Mauthner has taken the trouble to weigh the brains of 216 
children, of all ages, from birth up to the eighth year, so as to show the 
gradual and healthy increase of the organ. " During this time," says 
he, " we find a minimum of ten ounces, six drachms, rise to a maximum 
of forty-four ounces and a half. The average weight begins with thir- 
teen ounces and a half, and rises to thirty-five ounces and a half. During 
the first year it grows from thirteen ounces and a half to twenty ounces 
and a half, or seven ounces ; in the second, from twenty ounces and a 
half to twenty-five ounces and a half, or five ounces ; in the third, from 
twenty-five ounces and a half to thirty-two ounces, or three ounces and 
a half. Hence it appears that the brain grows most rapidly in the first 
year of life, that in the second and third years its increase is still consid- 
erable, but that its growth is slower after the fourth year. In conclu- 
sion, it may be observed, as a remarkable fact, that the minimum weight 
usually occurs in cases of atrophy or phthisis, and the maximum in pneu- 
monia, scarlet fever, apoplexy, and cerebral tubercle." 1 It also appears 
that the weight is to a great degree dependent upon the amount of blood 
contained in the brain. 

252. Symptoms. — The early period of the disease is marked by dul- 
ness, drowsiness, or apathy, with an apparently excessive size of the 
head. There is generally irritability of temper, giddiness, and habitual 
headache, with severe exacerbations. 2 

In passive hypertrophy, M. Mauthner remarks that the shape of the 
cranium is much changed, and the occiput occasionally prominent and 
globular; the parietal protuberances subsequently project; the coronal 
and sagittal sutures continue unossified up to the ninth or twelfth 
month, and the fontanelles much longer ; the growth of hair is scanty, 
and the veins of the scalp swollen. The child sleeps much, though 
easily startled; the head perspires a good deal, and droops forward by 
its weight. Attacks of crowing inspiration occur when the child cries, 
and not unfrequently end in convulsions, especially during the period 
of dentition. The digestion is impaired, and vomiting and diarrhoea 
are frequent. Gradually we find symptoms of compression developed, 
or they may suddenly appear as the result of the child being attacked 
by some other disease. 

"When hypertrophy of the brain has reached this stage, the skull 
deviates still more from its natural shape, the forehead sometimes be- 
comes prominent and globose, like the occiput, and while the skull goes 
on acquiring an increased curvature, the region of the temples continues 
flat, and thus contributes to give to the head the appearance of being 
formed by the union of the segments of four spheres. During this stage 
of the affection, the preternatural softening and thinning of the cranial 
bones corresponding to the prominences of the convolutions, are dis- 
tinctly perceptible, especially at the occiput. The functions of the brain 

1 British and Foreign Review, No. 42, p. 387. 

2 Condie, Diseases of Children, p. 383. 



180 HYPERTROPHY AND INDURATION OF THE BRAIN. 

become now much disturbed ; headache, giddiness, impairment of muscu- 
lar power, and loss of memory, occur ; the child grows sullen, peevish, 
sleepless, whimpers continually, and rolls the head constantly from side 
to side. At the same time it seems choked with phlegm, while the skin 
becomes every day more flabby, the muscles shrink, the bones grow soft, 
and the muscular power rapidly diminishes. Hence these children usu- 
ally lie on the back, breathing with habitual wheezing, and suffering 
from constant dyspnoea, with occasional asthmatic seizures, such as have 
been already described. When in this condition slight causes suffice to 
produce a general excitement of the vascular system, and to excite dis- 
eased action in other parts, which render still more obvious the influ- 
ence of hypertrophy on the nervous system generally. If the child 
happen to catch a slight cold, attacks of convulsions, cough, or of 
asthma, occur in consequence, or convulsions come on, which terminate 
life in a few days." 1 

253. When the disease is active (according to Mauthner), i. e., when 
the walls of the skull do not yield in proportion to the increase of the 
brain, the symptoms are those of more acute cerebral disease, the result 
of compression. There is also some modification of the symptoms, where 
the hypertrophy and induration are partial, according to the peculiar 
locality. Further, symptoms resembling those of hypertrophy, but 
very severe, have been noticed, where the skull is ossified and unu- 
sually thick, and does not yield to the increasing size of the brain. 

The intellectual faculties are generally enfeebled, but Dr. Elliotson 
relates a case in which they were rather increased in activity and 
power, and Dr. Condie mentions a child of five or six years old, whose 
head was as large as an adult's, and Avhose intellects were clear and 
acute. 2 This may be expected, if at all, in cases of such enlargement ; 
as the intellectual disturbance and many of the symptoms are the result 
of compression rather than of hypertrophy. 

The size of the head will vary a good deal, the younger the child the 
more distensible the cranium. Dr. Munchmayer 3 has noticed a peculiar 
prominence of the parietal protuberances, and this observation has been 
confirmed by Dr. Lee, who regards the symptom as a valuable distinc- 
tion between hypertrophy and chronic hydrocephalus. 4 The other 
symptoms especially noted by Dr. Lee in his cases were obtuseness of 
intellect, apathy, great irritability and excessive appetite. 

254. Drs. Sims and Green have noticed a sensation of firmness com- 
municated to the finger when the pressure is made upon the fontanelles, 
and regard this as a valuable diagnostic sign. 

Andr.al observed mania to occur in one case ; others have noticed 
delirium, and some idiocy, with a repetition of fits like epilepsy. 

The duration of life in children thus affected is subject to great 
variation. Some arrive at puberty with but little inconvenience ; but 
many die during childhood from the consequences of the hypertrophy, 

1 Mauthner., p. 174. British and Foreign Review, No. 42, p. 388. 

2 Diseases of Children, p. 883. 

3 Schmidt's Jahrbucher, vol. xxv., 1840. 
A Dublin Journal, vol. xxii. p. 24. 



HYPERTROPHY AND INDURATION OF THE BRAIN. 181 

such as convulsions, &c, or from states of the brain superinduced by 
other diseases. 

255. Patliology. — The change in the brain which strikes the eye at 
once is its increased size in most cases, and the evident flattening of the 
convolutions, diminished vascularity, and the absence of serum in the 
ventricles or at the base of the brain. When the head is much 
enlarged, the alteration in the consistence of the brain may not be very 
remarkable, although in general it will be found more dense than usual. 
But when the cranium has been ossified, or has not yielded to the pres- 
sure of the brain, the cerebral tissue will be found firm and elastic to 
the touch, and, cutting clear by the knife in thin slices, the gray matter 
paler than usual, and the white matter more brilliant. Or it may be 
still more firm, and offer some resistance to the knife or to pressure. 
Its weight is greatly increased, sometimes even doubled. 

"Professor Rokitansky states, as the result of many microscopic 
examinations, that its augmented bulk is not produced either by the 
development of new nervous fibrils, or by the enlargement of those 
already existing, but by an increase in the intermediate granular 
matter." 1 

According to Sims and Rilliet and Barthez, the hypertrophy and 
induration may be limited to the corpora striata or optic thalami, or to 
one lobe of the brain, which, of course, will condense the parts in its 
neighborhood more or less. 

The membranes of the brain are sometimes pale, sometimes injected, 
and distended so tightly by the brain that when an incision is made the 
brain protrudes. 

M. Mauthner has remarked a frequent coincidence of enlargement 
of the thymus gland, the left side of the heart, and the liver, thus 
affording some support to Munchmayer's theory of the connection of 
thymic asthma with hypertrophy of the brain. 

256. Causes. — Hypertrophy of the brain, or at least a condition of 
that organ strongly predisposing it to undue and more or less rapid 
augmentation of bulk, is very frequently congenital. 

All causes which give rise to cerebral congestion may, according to 
Hufeland, determine hypertrophy of the brain. 

Laennec, Papavoine, Rilliet and Barthez, mention an extraordinary 
and inexplicable effect of the preparations of lead in producing this 
disease ; but I do not find it mentioned by other authors. 2 

Dr. Lee regards the disease as " dependent upon or connected with 
struma." 

257. Diagnosis. — It is not very difficult in most cases to distinguish 
hypertrophy from acute hydrocephalus ; not because the symptoms of 
the former are so very clear, but because those of the latter are gene- 
rally sufficiently marked. Their acute inflammatory character, the high 
fever, quick pulse, and the sequence of symptoms, are very unlike 
hypertrophy. 

Chronic hydrocephalus has more resemblance to it, and especially in 

1 West's Lectures, Medical Gazette, August 27, 1847, p. 354. 

2 Mai. des Enfans, vol. i. p. 665. 



182 HYPERTROPHY AND INDURATION OP THE BRAIN. 

the most obvious characteristic, enlargement of the head. Mauthner 
has thus marked the points of difference : " In hypertrophy, the poste- 
rior part of the skull first presents an unnatural prominence. In chronic 
hydrocephalus, the forehead is the first part to present unnatural pro- 
minence. The altered direction of the eyes, and the very great width 
of the sutures and fontanelles, are likewise characteristic. In hyper- 
trophy, children lie horizontally, or throw the head back. In chronic 
hydrocephalus, children lie on the belly, with the head lower than the 
rest of the body, burying the face in the pillow. In hypertrophy, the 
face is puffy, the eyes inexpressive and staring, mouth half open. In 
chronic hydrocephalus, the countenance is withered, having the expres- 
sion of premature old age. In hypertrophy, functional disturbance 
comes on very gradually, not before the period of dentition or weaning, 
and consists at first in an affection of the respiratory apparatus, difficulty 
of breathing, and attacks of apncea. In chronic hydrocephalus, func- 
tional disturbance occurs early, and involves the cerebrum from the very 
beginning. In hypertrophy, the patient is fat and leucophlegmatic. 
In chronic hydrocephalus, the patient is ill nourished, subject to rickets 
and tabes mesenterica." 1 

Add to these, the projection of the parietal protuberance, observed 
by Drs. Miinchmayer and Lee, which is not observed in chronic hydro- 
cephalus. 

258. Prognosis. — The prognosis is in all cases serious, not so much 
from the dangerous character of the disease as from the effect pro- 
duced upon the brain by other causes, and its increased susceptibility 
to disease. There is more hope when it occurs before the sutures are 
ossified, and when the cranium yields readily to the increasing mass of 
the brain. When the skull is resisting, the result of compression may 
be fatal. 

At the same time, as Dr. Lee has observed, in the majority of cases, 
the post-mortem appearances do not throw much light upon the cause 
of death. 

259. Treatment. — When the disease is fully confirmed, there appears 
to be no means capable of reducing the volume of the brain ; and our 
principal efforts must be directed to guard against any attacks of con- 
gestion or inflammation, by means of leeches, cold lotions, purgatives, 
and counter-irritants. 

But, when the disease is commencing, we ought to prohibit everything 
which tends to produce excitement or determination to the brain. Quiet, 
rest, and tranquillity of temper should be observed, cold sponging of 
the scalp, and occasional purgatives. The hair should be cut short, and 
the head kept uncovered in the house. 

I do not know that iodine, either internally or externally, has been 
administered ; but it appears to me well worth a trial, in connection 
with other counter-irritants ; or the scalp might be painted with tincture 
of iodine at the same time that hydriodate of potash is given internally. 

The appetite, which is generally too good, should be restrained as 
to the quantity of food, and that not too nutritious in quality. The 

1 British and Foreign Medical Review, No. 42, p. 389. 



RAMOLLISSEMENT OF THE BRAIN. 183 

moment the gums become irritable they should be lanced, and the child 
should take plenty of exercise in the open air. 

Education must be carried on at a moderate rate, so as not to stimu- 
late the intellect too highly ; and it may be necessary to suspend it 
entirely at times. 

When the affection results from saturnine poisons, we are recom- 
mended to employ bloodletting, opium in large doses, cold applications, 
and evacuants, &c. 



II. RAMOLLISSEMENT, OR SOFTENING. 

260. There can be no doubt that encephalitis frequently terminates 
in softening, 1 even if we admit that the latter may occur independently 
of the former, as in some cases of hydrocephalus already noticed, and 
in other cases of old standing disease of the brain (tubercles, for 
instance), when the neighboring tissue is softened and pulpy. These 
are instances of secondary ramollissement. 

261. It does not appear that there is any symptom which positively 
indicates the occurrence of this lesion. Some French writers have 
regarded tonic contraction of one or more limbs as pathognomonic, and 
no doubt it frequently occurs ; but it is frequently absent, and it is also 
met with in other affections of the brain. In most cases, we have con- 
vulsions, paralysis, and coma as the principal symptoms ; sometimes a 
single convulsion, followed by coma ; in other cases, the convulsion is 
repeated. Occasionally, the loss of power is the most remarkable symp- 
tom succeeding the evidences of encephalitis just noticed ; sometimes the 
rigid contraction already mentioned, followed by relaxation and paraly- 
sis. Or there may be convulsion of one side of the body and paralysis 
of the other. 

In a case of M. Deslande's, quoted by Barthez and Rilliet, the child 
exhibited a slight but continual stupor, was very easily disturbed, and 
died without an additional symptom. In other cases, the coma is deep 
and permanent until death. 

In a few examples, not remarkable for any evidences of disease, the 
child has died suddenly during the night. 

We generally find complete loss of intelligence, as of voluntary 
motion ; the pulse is sometimes nearly natural, in other cases quick or 
irregular, and there is occasional vomiting. 

In one case, already quoted, the speech was impeded from the begin- 
ning, and ultimately rendered impossible — a fact which Dr. Abercrombie 
has noticed in adults. In some cases, there is squinting and retraction 
of the head. 

It is probable that softening of particular portions of the brain is 
attended by appropriate symptoms ; but it is excessively difficult to 
determine this point. 

I have seen a case of ramollissement of the cerebellum, the effect of 
inflammation caused by a fall, and which gave rise to very few symp- 

1 Abercrombie on Diseases of the Brain, p. 128. 



184 ABSCESS OP THE BRAIN.' 

toms, and those not characteristic. Frequent paroxysms of headache, 
vomiting, and loss of appetite ; but neither impaired intellect nor mus- 
cular power, and no affection of the bladder or genital organs. The 
pulse was quiet, the tongue clean, and there was no convulsion. 1 

262. Pathology. — Ramollissement, as Dr. Abercrombie observes, 
" consists in a part of the brain being broken down into a soft pulpy 
mass, retaining the natural color of the part, without any appearance of 
suppuration, and without fetor. This condition we often find as the only 
morbid appearance; but we frequently find it combined with the former 
(evidences of inflammation), one portion of the diseased mass presenting 
the deep red color, while another is in the state of ramollissement." 2 

The color of the softened mass is sometimes yellow. All such cases, 
Rilliet and Barthez think, are the result of secondary inflammation or 
softening. 

The consistence and extent of the softened portion vary much. It 
may be reduced to a kind of jelly or pulp, but without destroying the 
form of that part of the brain ; or it may be utterly disorganized, and 
fluid, or semi-fluid, like cream. So we may find it of small extent, 
limited to a portion of the brain, or occupying the greater portion of 
an hemisphere. Mauthner has observed that the white substance is 
almost always the seat of the disease in children, the gray matter being 
seldom affected. The disease is almost uniformly fatal, and of very 
short duration. 

263. The diagnosis is necessarily obscure. We may know that inflam- 
mation of the brain exists, and we may suspect that softening is taking 
place ; but that is nearly the only conclusion to which we can attain. 
The sudden paralysis, especially when combined with convulsion, the 
loss of the power of articulation, or the complete resolution of muscular 
force, appear to be more characteristic than any other symptoms. 

264. The fact that we cannot recognize with any certainty the dis- 
ease during life, that all the cases on record died, will at once explain 
our ignorance of any efficient mode of treatment. I have laid down 
the best mode of management for encephalitis; but I have no additional 
information to give as to any change of remedies required by this ter- 
mination. If the leeching, counter-irritation, and mercury have not 
secured the patient against this consequence of inflammation, we know 
not how to afford relief. 



III. ABSCESS OF THE BRAIN. 

265. In this affection, we find, according to Dr. Abercrombie, " a 
well-defined regular cavity, filled with purulent matter, generally lined 
by a soft cyst, and surrounded by cerebral matter in a healthy state." 3 

So few cases are on record that it is impossible to give a general 
description of the disease without calling in the aid of the imagination. 
I think it better, therefore, to quote two cases from Dr. Abercrombie's 
excellent work than to attempt any more formal statement. 

1 Dublin Journal, July, 1853. 

2 Diseases of the Brain, p. 72. 3 Ibid. 



ABSCESS OF THE BRAIN. 185 

The first occurred in a girl set. 5, and the case is described by Dr. 
Bateman. 1 "An abscess was found in the posterior part of the right 
hemisphere, inclosed in a fine vascular sac, and containing four ounces 
of pus. She was first affected with convulsion of the whole body, 
which continued for nearly two days ; during this time the left side was 
in a state of rigid extension, and the right was in constant motion ; and 
when the attack subsided the left side remained paralytic. She then 
had headache, squinting, blindness, and repeated convulsions ; and 
died after an illness of eleven weeks, having been comatose for only 
one day before her death. In some cases of this kind paralysis has 
occurred without convulsion, and in others convulsion without paralysis ; 
but one or other of these affections appears to be a common attendant 
on the encysted abscess." 2 

266. The next case I shall quote is that of a " girl set. 11, thin and 
delicate, who, after having complained for some days of headache, was 
seized on the 11th of January, 1817, with convulsion, which continued 
for about half an hour. I saw her on the twelfth, and found her 
affected with severe headache and paralysis of the right arm, which had 
taken place immediately after the convulsion. The pulse was 100, the 
tongue foul, the face rather pale, and the eyes languid. Being bled 
from the arm and purged, she was much relieved. On the 13th the 
pulse was natural, the headache was much abated, and she had reco- 
vered considerable motion of the arm. On the 15th, the headache being 
increased, and the arm more paralytic, she was bled again ; and on the 
16th and 17th she was much relieved, the pulse natural, and the motion 
of the arm much improved. On the 18th, after being affected with 
increase of headache and some vomiting, she became convulsed, the 
convulsion being confined entirely to the head and the right arm. The 
head was drawn towards the right side, with a rolling motion of the 
eyes ; the arm was in constant and violent motion ; she was sensible, 
and complained of headache ; pulse 100. Being bled to oviij, the 
convulsion ceased instantly, and the headache was relieved, but the 
right arm continued in a state of complete paralysis. 19th and 20th, 
the arm had recovered a little motion ; some headache continued, with 
occasional vomiting ; pulse 60. On the three following days the con- 
vulsive attacks returned several times ; they did not now affect the head 
or face, but were entirely confined to the right arm, which after the 
23d was left in a state of permanent paralysis. Hitherto no other part 
of the body had been affected by the convulsion, but on the 24th it 
attacked the right thigh and leg, and left them in a state of paralysis ; 
pulse 60. The former remedies were again employed with activity, 
without any effect in arresting the progress of the disease. The thigh 
and leg now went 'through a course precisely similar to that described 
in regard to the arm, and on the 29th remained in a state of perma- 
nent paralysis. When the convulsion first began to affect the leg, the 
arm was affected at the same time; but afterwards it was confined to 
the thigh and leg, the arm remaining motionless. February 4. — Com- 

1 Edinburgh Medical and Surgical JourDal, vol. i. p. 150. 

2 Abercrombie on Diseases of the Brain, p. 111. 



186 TUMORS OR TUBERCLES OF THE 

plete paralysis of the whole right side ; no return of convulsion ; she 
continued quite sensible, and made little complaint : pulse from 50 to 
60. She now continued for several days without any change, and, 
except the palsy of the right side, every function was natural. She 
was quite sensible, appetite good, pulse and vision natural, and she 
made little complaint of any uneasiness. She was, however, inclined 
to lie without being disturbed, and gradually became more oppressed. 
On the 11th this had increased to perfect coma, in which she continued 
for three days, and died on the 14th. 

" Inspection. — In the upper part of the left hemisphere of the brain 
there were two distinct, defined abscesses, containing together from 
six to eight ounces of very fetid pus. They were lined by a firm white 
membrane, and a thin septum of firm white matter separated them 
from each other ; the one was in the anterior part of the hemisphere, 
very near the surface, and the other immediately behind it. They had 
no communication with each other, or with the ventricle. In the pos- 
terior part of the right hemisphere there was a small abscess containing 
about half an ounce of pus. There was no serous effusion in any part 
of the brain, and no other morbid appearance." 1 



CHAPTER IX. 

TUMORS OR TUBERCLES OF THE BRAIN AND SPINAL MARROW. 

267. Besides the tubercular disease of the membranes of the brain 
already described (182), we find larger and more isolated deposits of 
the same matter, or tumors of a different kind, growing from the mem- 
branes or imbedded in the substance of the cerebrum, cerebellum, and 
spinal marrow, attended by symptoms which indicate their presence 
but very obscurely, and having almost always a fatal termination. 

This form of disease is not very common, though more frequent than 
was suspected, until the more accurate researches of late years by 
Green, Barrier, Rilliet and Barthez, West, &c. It occurs too at an 
earlier age, for of thirty-four cases mentioned by Barrier, sixteen were 
under five years ; thirteen from five to ten ; and five only from ten to 
fifteen years. Of Dr. Green's thirty cases, in thirteen it occurred be- 
tween two and four years ; and in seventy-five cases he states that it 
occurred most frequently in children from three to seven years. Of 
Rilliet and Barthez's twelve cases, six were from three to five years ; 
four from six to ten and a half; and two from eleven to fifteen years ; 
and eight were boys. Dr. Condie considers it very rare before the first 
year. Dr. Mauthner found, in seventeen out of thirty-two, that the 
age did not exceed six years, which was the case in seven out of eight 
cases observed by Dr. West. On the other hand, it is very rare in 
adults, according to Cruveilhier, Louis, and Lugol. 

1 Abercrombie on Diseases of the Brain, p. 93. 



BRAIN AND SPINAL MARROW. 187 

The sex of the child does not appear to have any influence in the 
production of the disease ; the majority of Dr. Green's cases were fe- 
males ; the majority of Rilliet and Barthez's cases males. 

268. Symptoms. — Dr. Abercrombie has observed, with great truth, 
that " the symptoms accompanying tubercular disease of the brain in 
its early stages, are often exceedingly obscure and variable ; perhaps 
little more than a tendency to headache, which assumes no formidable 
character, or sometimes assumes the appearance of what has been 
called the periodical headache, or the sick headache. The symptoms 
may go on for a long time in this manner without exciting any alarm, 
until the disease suddenly assumes a more active character, and is 

lily fatal." 1 

In five of Dr. Green's thirty cases, there was no symptom at all of 
cerebral disorder ; in three, headache was the only symptom ; in one, 
deafness ; and in one, a purulent discharge from the ear. Moreover, 
we find it extremely difficult to draw the line between the symptoms 
which arise from the tumor simply, and those which are the result of 
the morbid action which it provokes in the neighboring tissues. 

Headache is, perhaps, the most universal symptom ; it may be either 
general or local, but in the latter case it does not necessarily mark the 
seat of the disease. In general it is also an early symptom, and corre- 
sponds with the remissions and accessions of the constitutional disturb- 
ance ; it may continue even until death. In more cases it is absent at 
the commencement, and is noticed only at an advanced period of the 
disease. 

269. The organs of sense are generally more or less affected ; the 
touch the least so, however. Occasionally, at first, it seems more acute, 
but subsequently less sensitive, especially when the tumors are seated 
in the cerebellum, or near the sensitive nerves. M. Barrier mentions a 
case in which there was paralysis of the trifacial nerve of the right 
side, in consequence of the tumor pressing upon the fifth pair of 
nerves. 2 

The eye and ear will be similarly affected by the pressure of the 
tumor in the neighborhood of their spinal nerves, and more or less by 
the general disturbance of the nervous system, from cerebral tumors. 
Amaurosis and deafness are not uncommon ; and it is, perhaps, Worth 
noting, that in a certain number of cases there is a discharge from the 
ear, or an abscess of that organ, 3 but whether connected, as cause or 
effect, with the tubercles, it is not easy to say, but as yet I am inclined 
to think not. 

270. During the early stage of the disease, and so long as it is un- 
complicated, there is rarely much disorder of the intelligence. In some 
cases, it is true, the temper becomes irritable, especially if the headache 
is severe ; or perhaps the child may lose its natural vivacity, and be- 
come apathetic and dull, weary of play, and wishing to be alone. 

At a more advanced period of the disease, even when uncomplicated, 

1 On Diseases of the Brain and Spinal Marrow, p. 167. 

2 Mai. de l'Enfance, vol. ii. p. 630. 

3 Dr. Green, Med. Cliir. Trans., vol. xxv. p. 193. Abercrombie on Diseases of the 
Brain, &c, p. 171. 



188 TUMORS OR TUBERCLES OF THE , 

so far as we can ascertain, there gradually steals over the countenance 
an expression of mental feebleness and vacuity ; the child is indisposed 
to intellectual exertion, even if not actually incapacitated. In propor- 
tion as morbid actions (meningitis, encephalitis) are excited by the 
tumors, we find the mind exhibit the same disturbance as is usual in 
these disorders. 

271. Convulsions are by no means uncommon, though not universal ; 
they pretty constantly occur in those cases where the tubercles occupy 
the central portion of the brain, or are disseminated extensively through- 
out. Rigidity or contraction of one or more of the extremities is more 
common ; it generally affects the leg and arm of the same side, some- 
times only one limb, and very rarely both upper or both the lower limbs. 
It is not easy to determine whether it be referable directly to the pres- 
sure of the tumors, or whether it be the result of the inflammation and 
induration, or softening of the surrounding cerebral substance (261). 
Or perhaps we may observe a weakness of certain muscles, as in a case 
of Dr. Green's, where the eyeball was convulsively jerked inwards, or 
in other cases, in which strabismus occurs. 

In the majority of cases, paralysis occurs at some period of the dis- 
ease ; at the commencement in a few, and at a more advanced period in 
most instances. It may be partial, the result of local pressure, or 
affecting generally the sensation and motion of one side. It is remark- 
able that although the child may recover partially and for a time from 
the affection of the eyes and ears, from the rigidity and deficient sensi- 
bility ; the paralysis is permanent in almost every case in which it 
occurs, and continues without mitigation. 

272. The stomach and bowels generally sympathize with the cerebral 
irritation, and, coincident with the headache, stupor, or coma, we find 
vomiting to occur; and constipation, sometimes easily overcome, but in 
other cases very obstinate. 

The circulation is generally affected, but in an uncertain manner ; 
the pulse is sometimes slow, sometimes quick ; in other cases very un- 
equal. My friend Dr. Chas. Johnson attaches great value, as a pathog- 
nomonic sign, to irregularity of the pulse, occurring at an early period 
of the disease, and without apparent cause. So far the symptoms may 
be considered the result of the tubercles alone, and they do not differ, 
whether the seat of the tumor be the cerebrum or cerebellum ; and they 
may persist, with intermissions or remissions of varying duration, for a 
considerable time, and then the child gradually sinks into stupor and 
coma, and at length dies. Or, which is more frequently the case, a 
secondary affection, meningitis or encephalitis, may be excited, giving 
rise to the symptoms formerly described, and masking the proper cha- 
racteristics of the present affection, and proving certainly fatal. Some 
cases have terminated in chronic hydrocephalus when the tumor has 
been so situated as to press upon the large veins or sinuses, or to offer 
considerable mechanical interruption to the circulation. Nine of Dr. 
Green's cases died with symptoms of acute hydrocephalus, and a few 
with those of softening of the brain. 

In many cases there are tubercular or scrofulous affections of other 
organs, which are of value in forming a diagnosis. 



BRAIN AND SPINAL MARROW. 189 

273. The duration of the disease is very difficult to be determined ; 
the tumors may be latent for a long time ; the early symptoms are 
slight and undefined, and even when marked, they are common to other 
diseases, or occur frequently without any diseases at all. Dr. Green 
remarks that in his cases the chronic stage varied from six weeks to two 
years. 

Rilliet and Barthez state that of twenty-five cases of tubercles with 
or without chronic hydrocephalus, the disease lasted in 

3 cases from 3 to 4 months. 

10 " 5 to 7 

3 " 7 months to 1 year. 

2 " 1 year to 2 years. 

3 cases for several years. 

And the termination is uncertain, generally occasioned by a secondary 
complication, and more quickly than would have happened from the 
simple disease. 

I have already spoken of the complications, but as they are of great 
importance I may as well enumerate them again. 1. Meningitis, either 
the simple acute or the tubercular form, not unfrequently the latter, 
and not unnaturally owing to the tubercular cachexia. 2. Inflamma- 
tion of the substance of the brain, with (probably), first, some degree of 
induration, and thenramollissement. 2. Effusion of fluid into the ventri- 
cles, distending them, and compressing the brain, and constituting a 
simple form of chronic hydrocephalus. 4. Scrofulous or tubercular 
disease of the chest or abdomen, becoming active, and in its effects 
superseding the disease of the brain or cerebellum. 

274. Pathology. — Tumors of the brain and cerebellum are of different 
kinds. Dr. Monro mentions a hard tumor of a dirty yellow color 
growing from the innersurf ace of the dura mater, 1 and occasionally 
imbedded in the brain ; scrofulous, adipose, scirrhous, and ■ encysted 
tumors, but they are very rare in children, with the exception of the 
scrofulous or tubercular. 

Constant found that in four years, at the Hopital des Enfans, he met 
with but three kinds of tumors of the brain — tubercles, cancer, and 
acephalocysts, and that the frequency of the first, compared with the 
latter, was as 40 to I. 2 

Dr. Abercrombie described a tumor compressing the brain, which was 
formed of a "mass of pellucid albuminous matter," lodged under the 
arachnoid; "it resembled much the albumen of an egg, but was much 
firmer, so that pieces of it could be separated from the mass, and lifted 
up. Parts of the mass, being thrown into boiling water, became imme- 
diately opaque and coagulated." 3 

275. But by far the most common kind of tumor of the brain in 
children consists of deposits of tubercular masses, varying in size from 
a pea to a hen's egg, and in number from one to fifty. 4 The character 
of these masses is that of the ordinary tubercular matter ; we often find 

1 On the Morbid Anatomy of the Brain, p. 45. 

2 Gazette Medicale, 1836, p. 487. 3 Diseases of the Brain, &c., p. 178. 
4 Dr. Green, Med. Chir. Trans., vol. xxv. p. 199. 



190 TUMORS OR TUBERCLES OF THE 

them in a crude state, or perhaps softened in the centre, 1 generally 
very firm, yellowish or greenish in color, less friable than tubercles 
in the lungs or lymphatic glands, and in appearance like Gruyere 
cheese. Their form is generally globular, with irregular surfaces; oc- 
casionally, however, the shape is modified by pressure, or by the junc- 
tion of several smaller masses. It has been a matter of dispute whether 
they possess a regular cyst, but the general opinion seems now to be 
that they do not, but that the appearance of cellular membrane between 
them and the central substance is either the remains of the pia mater, 
or irregular unconnected shreds of cellular membrane. Barrier remarks 
that whenever a well-marked cyst exists, it always surrounds an ancient 
tumor suppurated in the centre. The tumors are generally situated in 
the cellulo-vascular tissue of the pia mater, and as they increase they 
depress the substance of the brain or cerebellum, and, as it were, bury 
themselves in it, except at one point, where they are adherent to the 
membranes. In other cases, but by no means frequently, they are formed 
actually in the cerebral substance, unconnected with the membranes. 

The tubercles may occupy either hemisphere of the brain, or both, 
the cerebellum or the pons Varolii, or we may find them in more than 
one place in the same case. Dr. Green observes: "In the thirty cases 
contained in my table, the tubercular deposit existed eleven times in the 
hemisphere of the cerebrum, nine times in the cerebellum, seven times 
in the cerebrum and cerebellum together, and twice in the cerebellum 
and pons Varolii together. I have, however, notes of two cases in 
which the tubercle was confined to the pons Varolii. 

276. So much for the tumors themselves ; but as a careful analysis 
shows that the more marked symptoms, especially in the more advanced 
stage of the disease, arise rather from morbid conditions of the sur- 
rounding brain or membranes than from the mechanical pressure and 
irritation of the tumor, it is of great consequence to notice these condi- 
tions. In some rare cases no change could be detected in the mem- 
branes of the brain, but in the majority there are decisive evidences of 
inflammatory action. The membranes may be thickened or injected, 
and adherent to the cortical substance, and simple or puriform fluid 
effused. The surrounding cerebral structure may be injected and soft- 
ened, but superficially, or the softening may be extensive and deep, with 
evidences of inflammation 2 or without. In some rare cases the surround- 
ing substance is fuller and more firm than usual, as if slightly indurated ; 
in others it appears hypertrophied. Lastly, the ventricles are some- 
times largely distended with fluid, as in chronic hydrocephalus, the con- 
sequence, most probably, of mechanical obstruction to the circulation, 
occasioned by the pressure of the tubercles. 

277. Causes. — No doubt the deposit of tubercle in the brain depends 
upon the same state of constitution which occasions its presence in the 
lungs or any other organ, and beyond this we know little or nothing. 
There must be some peculiar cause, certainly, for its greater frequency 
in children than in adults; for whilst Cruveilhier, Louis, Lugol, and 

1 Monro, Morbid Anatomy of the Brain, p. 51. 

2 Moncrieff's case in Monro on Morbid Anatomy of Brain, p. 51. 



BRAIN AND SPINAL MARROW. 191 

Abercrombie afford testimony to its rarity in adults, Dr. Green found it 
once in every fifty-one cases out of 1824 admitted into the Children's 
Hospital ; and the testimony of Barrier, Constant, Rilliet and Barthez, 
&c, confirms this fact. Scrofulous diathesis, hereditary predisposition, 
and age, therefore, all appear to aid in determining the deposits of 
tubercular matter in the brain, and this is really all our positive know- 
ledge of the subject. 

278. Diagnosis. — After the description I have given, I need hardly 
say that the diagnosis of tubercles, or tumors of the brain, in children, 
is extremely difficult, not only from the absence of any very character- 
istic symptom, but from the irregularity and distance of the symptoms 
which do arise. In general we can only arrive at a presumption by 
carefully collating all the symptoms, their sequence and relation, with 
the history, habits, and constitution of the patient. My friend, Dr. 
Charles Johnson, relies much upon the occurrence of irregularity of the 
pulse at an early period, when other symptoms which might explain it 
are absent. The most common and best marked symptom is the headache, 
which is either persistent or in paroxysms, and often circumscribed, to- 
gether with emaciation, without apparent organic disease. But it may 
be months before any other decided evidence of cerebral disease is de- 
veloped. Dr. Adams mentions scrofulous habit, paroxysmal headaches, 
vomiting, convulsions, muscular tremors and weakness of the limbs, with 
variations in the pulse, as the principal diagnostic symptoms. "When, 
however, a child has suffered for some time from severe headache, when 
the headache is followed by convulsive movements, some paralytic affec- 
tion, amaurosis, contraction of muscles, occasional vomiting, accesses of 
fever, and the train of symptoms already mentioned, and when these 
symptoms succeed each other at various intervals of weeks or months, 
we have very great reason to believe that the child has tubercle of the 
brain." 1 

M. Rilliet founds his diagnosis of cerebral tubercle upon the follow- 
ing general considerations: 1. The age of the child, the disease being 
much more frequent after than before the age of three years. 2. The 
circumstances which preceded the attack, and particularly the causes 
under the influence of which the disease was developed. 3. The state 
of health at the period of invasion. 4. The primary symptoms, as con- 
vulsions, lancinating headache (continued or intermitting), paralysis, 
amaurosis, and much more rarely, rigidity. 5. Lesions of the cranial 
parietes, exophthalmia, nasal or auricular discharge coinciding with cere- 
bral symptoms, or having been preceded by continued vomiting. 6. 
The chronic progress of the symptoms, for time alone will sometimes 
discover the nature of the disease. Chronic symptoms with reference 
to motility are more to be depended on than disorders of the intellect. 
7. It is necessary to keep in remembrance the great frequency of tuber- 
cular disease in childhood and the infrequency of other kinds of chronic 
cerebral disease. 

279. Still more difficult is it to determine the locality of the tumor; 
certainly the pain is often limited and fixed in one spot, as, for example, 

1 Dr. Green, Med. Chir. Trans , vol. xxv. p 207. 



192 TUMORS OR TUBERCLES OF THE 

at the occiput when the tumor is in the cerebellum, and in some cases it 
has suffered for a direct diagnosis; but it is by no means certain; the 
pain is often too general, and when localized it has been found not to 
correspond with the seat of the tumor. 

The pressure of the tumor upon some spinal nerves, or origins of 
nerves, may give rise to symptoms which explain their source, but these 
cases are very rare. In like manner the symptoms which arise when 
the tumor is seated in the spinal cord possess more peculiarity, as we 
shall see presently. 

As to our distinguishing between different kinds of tumors, all we can 
effect is a calculation of probabilities. We have the evidence of M. 
Constant, already quoted, that tubercles are forty times as frequent as 
any other tumor of the brain in children ; and if, in addition, we can 
ascertain the presence of scrofulous diathesis, the presumption will be 
altogether in favor of tubercle. 

280. The prognosis is, in all cases, unfavorable. Almost all die, 
either of the wasting and suffering caused by the tubercle, or of some 
cerebral disease excited by it. Yet neither can we say that tubercles 
are absolutely incurable, for there is evidence that they may be arrested, 
absorbed, or transformed at an early period. In a case of M. Leguil- 
lon's, quoted by M. Barrier, the child showed symptoms of tubercles 
four years before its death, and after death they were found to have 
become calcareous. 

281. Treatment. — In so hopeless a disease little is to be expected 
from treatment, and on that account, perhaps, too little effort has been 
made to afford relief. So long as we have to deal with the effects of 
the tumors simply, our chief remedy is counter-irritation employed 
pretty freely. Gendrin thinks that it is used too timidly, and has failed 
in consequence. 1 He advises large moxas to the temples, to the neck, 
behind the ears, &c. I really think that a succession of blisters to the 
head, and a seton or issue in the neck or arm, will be found as useful 
and far less painful. 

The general treatment of tubercles must also be adopted; and it may 
be worth while, at an early period, to give iodine a fair trial. 

282. But when secondary affections arise, such as acute meningitis, 
chronic hydrocephalus, &c, the treatment will require modification, 
and it may be necessary to adopt more active measures. The treat- 
ment I have already laid down for these diseases will be proper, in a 
minor degree however, under these circumstances, proportioning it to 
the violence of the disease, the strength and constitution of the child, 
&h. 

The diet should be light and nourishing, but not stimulant ; and the 
child should, at an early period, be much in the open air. 

283. I have mentioned that tubercles are occasionally developed in 
the spinal cord or its membranes. Ollivier has recorded a considerable 
number of cases, 2 and he remarks that although there are cases on 
record where the tumor occupied the lower portions of the spinal mar- 

1 Translation of Abercrombie, p. 262. 

2 TraitS de la Moelle Epiniere, &c, vol. ii. p. 272. 



BRAIN AND SPINAL MARROW. 193 

row, yet that they are much more common in its superior portion. 
The symptoms in many cases are as few and obscure as in tubercle of 
the brain ; in others we find convulsive movements, contraction, epilepsy, 
feebleness of limbs, loss of sensibility, retention of urine, constipation, 
&c. &c. 

A certain amount of disturbance is due, doubtless, to the mechanical 
pressure of the tubercle, but still more to the congestion, inflammation, 
and softening of the surrounding tissues, which are observed in the 
spinal cord, just as we found them in the brain. 

284. My friend, Dr. Geoghegan, of this city, has recently published 1 
a very interesting case of a scrofulous tumor in the lower portion of the 
spinal column, some of the details of which I am tempted to extract, in 
the absence of any systematic statement of this disease. 

"A boy, set. 7, of tolerably healthy appearance, was admitted into 
the city of Dublin Hospital in September, 1847, laboring under well- 
marked paraplegia, and who presented the following conditions : Com- 
plete paralysis of sensation of the lower part of the body, commencing 
at a point a little above the upper margin of the pelvis ; severe pinch- 
ing, or the introduction of a needle, not eliciting the slightest indication 
of pain. Complete loss of voluntary motion of the same parts, except 
of the muscles concerned in the adduction and rotation inwards of the 
thighs, which retain a very slight degree of power. The muscular con- 
tractions depending on excito-motory power in the paralyzed parts are 
extremely well marked ; pinching of the integuments of the legs, thighs, 
scrotum, penis, and lower part of the abdomen, producing abrupt mo- 
tion, chiefly in the flexion of the leg. These effects are most intense 
when the stimulus is applied to the integument of the penis or scrotum. 
When the soles of the feet are tickled, the legs are retracted. Marked 
motion of the lower extremities is also produced on pressing on the 
sacrum. The feet are cold, and the legs and thighs somewhat flexed 
and rigid, conditions which increased as the case progressed. There is 
incontinence of urine and feces, the former of which, it is stated, did 
not immediately follow the paralysis of the limbs. The sphincter ani, 
when in repose, is closed, and grasps the finger moderately when intro- 
duced within it. Irritation of the integument covering the sphincter 
produces abrupt contraction of the muscle. There is stillicidium of 
urine, which is converted for a few moments into a stream, when the 
boy is placed on his face. On one occasion the catheter having been 
introduced after the patient had been lying on his back, two or three 
ounces of turbid, faintly acid urine, admixed with pus globules, were 
withdrawn, the operation producing partial erection of the penis. The 
fluid removed became putrid and ammoniacal in three hours afterwards." 
A little precaution prevented the recurrence of this condition of the 
urine. 

" On examination of the spinal column, with a view to the detection 
of the cause of the preceding phenomena, no deviation from its natural 
figure was discernible. From about the fifth to the eighth spinous 
process of the dorsal vertebrse, tenderness is evinced oa percussion, 

1 Med. Press, March 8, 1848. 

13 



194 TUBERCLES OF THE BRAIN AND SPINAL MARROW. 

but not on firm pressure. The functions of the brain are perfectly 
natural ; the child, however, seeming more lively than is usual at his 

a S e '" 

" It appeared that since last April this patient had suffered from un- 
easiness in the back, in the situation of the tenderness, although, from 
his silent habit, he did not complain of pain ; he used frequently, how- 
ever, to place his hand on the affected part. About the latter end of 
September his legs were observed to drag in walking, and pains in his 
lower limbs were experienced. While out airing he suddenly stopped 
and fell, but is reported to have walked home with little assistance, and 
also to have gone to bed without help. Next morning it was discovered 
that he was perfectly paralyzed in his lower limbs." 

Dr. Geoghegan came to the conclusion that either a tumor existed in 
the spinal cord, or that the investing membranes were considerably 
thickened. Issues were reintroduced, and iodide of potassium given, 
with a generous diet, and attention to the bowels. For some time the 
symptoms continued the same, with emaciation ; but " about the early 
part of January symptoms of cerebral disturbance manifested them- 
selves ; frontal headache, stiffness of neck, and retraction of head ; 
slight dilatation of pupils, which were contractile, but oscillating under 
the appearance of a fixed current of light ; slowness and irregularity of 
pulse ; incapacity to answer questions ; although volition, in its minor 
grades, is still capable of being roused, either through the intervention 
of common or spinal sensation : in a word, symptoms of effusion within 
the head were manifest. Notwithstanding suitable treatment, he sank 
about the middle of the month." 

On dissection there was observed moderate venous congestion of the 
brain, with some effusion ; the upper part of the spinal cord, as well as 
the brain, was free from disease ; but " at a point corresponding to the 
tenth dorsal vertebrae, before the theca was divided, a very perceptible 
enlargement of the spinal cord was discovered." " On dissection of 
the diseased portion, it was observed to be of a light, sulphur-yellow 
color, having much the aspect of matter often found in scrofulous 
glands, containing a few minute cavities, and having embedded in its 
lower parts a distinct reddish-gray mass, about the size of a pea. The 
tumor, generally examined by a lens, possessed a coarsely granular 
texture, and throughout the greatest part of its length had completely 
supplanted the natural texture of the cord ; but, from its oblong oval 
figure, its upper extremity and the superior part of its lateral surfaces 
were invested with a thin coating of nearly healthy medullary texture. 
The mesenteric glands were enlarged, internally of a reddish-gray 
color, and gray externally. The lungs contained a considerable quan- 
tity of crude tubercles. The rectum was natural, and the urinary blad- 
der contracted and empty ; its mucous surface not thickened or ulcer- 
ated, and presenting livid patches of venous submucous congestion. 
The total thickness of its eoats, a quarter of an inch." 

285. It is more than probable that any treatment will fail in relieving 
this form of disease ; but as it is our duty to make a trial, there appears 
more hope from counter-irritation, iodine, and due attention to the 
stomach and bowels, than from any other plan. 



CONGESTION AND APOPLEXY OF THE BRAIN. 195 



CHAPTER X. 

CONGESTION AND APOPLEXY OF THE BRAIN. 

286. I have already alluded to an effusion of blood which takes 
place between the cranium and dura mater during parturition, under 
the term "subcranial cephalsematoma" (103), and the effects of which 
are manifested shortly after birth, and which generally terminates fa- 
tally. Of eight cases collected by Dr. West, two were stillborn, one 
died on the fifth day, two on the ninth, and two on the twenty-first. 

I have now to direct the reader's attention to effusions occurring 
after birth, from the age of one or two days up to the period of puberty; 
and I may remark that, whilst the disease is more frequent than has 
been imagined among children, it appears more common at an early age 
than subsequently. 

Dr. Evans Kennedy and Dr. Doherty have related several cases in 
which it occurred a few days after birth. 1 

Dr. Condie mentions that during the thirty-eight years preceding 
1845, there occurred in Philadelphia sixty-nine deaths from apoplexy 
in children under ten years of age, viz : in those under one year, 
twenty-seven cases ; between one and two years, sixteen ; between two 
and five, fourteen ; and between five and ten, twelve. 2 

Rilliet and Barthez give thirty-eight cases: four under two years ; 
ten between two and three ; six between three and five ; six from five 
to seven ; three from nine to ten ; and seven from ten to fourteen years 
of age. 

It occurs both in children apparently healthy, and in those of de- 
ilitated constitutions. 3 

287. As in adults, we find different degrees of morbid action giving 
rise to nearly the same symptoms and similar results. 

I. We find that a child may die of apoplexy apparently, and on 
making a post-mortem examination we may discover nothing but ex- 
cessive vascularity of the brain or membranes resulting from con- 
gestion. 

II. If the congestion of the membranes be carried to a very great 
extent, the blood escapes drop by drop, or exudes into the cavity of 
the arachnoid, or into the ventricles, giving rise to the variety called 
by M. Serres apoplexie meningienne, and which comes next in fre- 
quency to the congestive apoplexy, and occurs chiefly between one and 
five years of age. 

in. When the vessels which supply or permeate the texture of the 

1 Dublin Journal, vol. x. p. 421 ; vol. xxv. p. 49. 2 Diseases of Children, p. 888. 
3 Cases by Quain, Lond. Journ. of Med., No. 1, p. 27. 



196 CONGESTION AND APOPLEXY OF THE BRAIN. 

brain are subjected to great pressure by the accumulation of blood, 
their tunics may give way, and the blood escapes into the substance of 
the brain, constituting the ordinary apoplexy of advanced life. This 
variety is more rare than the others, and is generally observed a few 
years later. 

288. Let us first consider the congestive apoplexy of young infants. 
It cannot be a matter of surprise that the vascular action of the brain 
in infants should be liable to violent and extreme disturbances, nor that 
these irregularities should act powerfully upon that organ ; the diffi- 
culty is to explain why mischief does not more frequently result. 

The attack is generally sudden, but in some instances we find it 
preceded for a few days by a disorder of the stomach and bowels ; or 
it may occur in the course of some other disease, as ramollissement of 
the brain, hooping-cough, &c, or after convulsions. Barrier mentions 
its occurrence in a case of general oedema. 

The symptoms are, more or less complete stupor, lividity of the face, 
which appears tumid, contraction and insensibility of the pupils, labo- 
rious respiration, hemiplegia, or occasionally rigidity of the neck and 
lower extremities, and sometimes convulsions. 

If not relieved, those symptoms increase in intensity, and the child 
dies comatose. 

M. Constant relates the case of a girl who died thirty hours after 
admission into the hospital, apparantly from hemorrhage into the brain. 
There was loss of power in all the limbs, insensibility, loss of intelli- 
gence, and stertorous breathing. On dissection, nothing but extreme 
congestion of the brain was discovered. 1 

289. When the congestion is confined to the spinal marrow, the symp- 
toms are nearly the same ; convulsions are more frequent, there is great 
drowsiness or stupor, the corners of the mouth are drawn downwards, 
and sometimes the arms are pressed close against the side, or paralysis 
may occur. 

290. Meningeal apoplexy, which constitutes one-third of the causes 
of death in stillborn infants, according to Cruveilhier, 2 occurs also after 
birth, during the first few hours or days of life, as well as subsequently. 
It is not easy to explain why it should occur previous to birth in many 
cases, for in them there has been neither undue pressure in the use of 
instruments nor undue delay in the expulsion of the body after the 
transit of the head ; but in other cases it sometimes occurs that after 
the head is born the uterine contractions cease for a time, and then the 
veins of the neck are compressed by the external orifice, and the cord 
by the body of the child against the walls of the pelvis ; the face 
becomes livid, purple, almost black, and if the infant be not quickly 
extracted it may die of apoplexy. The same result may occur in 
breech, footling, or funis presentations. 

291. The symptoms which are developed in young infants some time 
after birth are very like those of inflammation, and may easily be mis- 
taken for them. M. Legendre, who has carefully investigated that 
subject, remarks : "After two or three vomitings, or even without 

1 Ga2. Med., 1835, p. 572. 2 Anat. Path., livr. xv. p. 1. 



CONGESTION AND APOPLEXY OF THE BRAIN. 197 

previous vomiting, the infants were attacked with fever and some con- 
vulsive movement, most frequently of the globe of the eye, and having 
some degree of strabismus ; the appetite was lost, thirst great, the 
evacuations natural or easily excited. Soon after, there was permanent 
contraction of the feet and hands, followed by tonic or clonic convul- 
sions. During the convulsions, sense and sensibility were abolished, 
and the face, ordinarily congested, became of a deeper color. During 
the intervals there was drowsiness and stupor, which, slight at first, 
increased as the disease made progress ; the fever continued, and 
became more intense as they approached the fatal termination. Lastly, 
the convulsions, at first more or less distant, became more and more 
frequent, and, during the last period,, almost constant." 1 

In other cases, the incursion is more sudden and marked ; the child 
becomes suddenly drowsy, stupor and coma come on, convulsions or 
paralysis, and death follow rapidly. The difference of symptoms and 
their intensity will depend very much upon the amount of effusion. In 
some cases convulsions are almost the only symptom observed, as is 
stated by Dr. Schleifer to have been the case in the Foundling Hospital 
at Prague. Paralysis is much less frequent. M. Legendre met with 
it once in nine cases, and Rilliet and Barthez once in seventeen. 

292. The course of the disease depends a good deal upon the amount 
of effusion. When it is great, and has been quickly effused, speedy 
death is the result. And, no doubt, the great majority of all cases die; 
but, whilst very few indeed recover, the disease changes its character in 
some cases, and becomes chronic. In young infants, before the skull is 
completely ossified, a proportionate amount of distension may take 
place, and the brain, relieved of some of the pressure, to a certain 
extent becomes accustomed to and tolerant of the remainder, the effused 
blood separates into its two portions, the more solid is partially, at 
least, absorbed, the fluid rather increased, a sort of cyst is formed 
around it, and the child exhibits the symptoms, not of apoplexy, but 
of chronic hydrocephalus (226), except that the head is more unequally 
enlarged, running the same course, and ultimately proving fatal. 

Both the acute and chronic forms of the disease, however, are very 
often shortened by secondary attacks of thoracic or abdominal inflam- 
mation. This was the case with most of M. Legendre's cases. 

293. Cerebral apoplexy, or effusion of blood into the substance of the 
brain, is much more rarely observed. Guersent states that he saw but 
two cases in twenty years' practice. Becquerel mentions that in three 
years, and among four hundred autopsies, he has not met a single case 
of simple hemorrhage into the cerebral substance. 

Some cases, however, have been recorded. M. Rochoux, in 1833, 
has collected eight cases, one by a physician at Breslau, and one by 
M. Guibert (93t. 14) ; one by M. Payen (set. 12); one, of a child ex- 
posed to the sun, by M. Andral (get. 12) ; another of a child who, after 
being exposed to the sun, died suddenly (in a fit of anger) from hemor- 
rhage into the cerebellum ; one by Tonnelle" (set. 2) ; one by Burnet 
(set. 1) ; and one by M. Serres (set. three months). Since then, Lalle- 

1 Bouchut, Mai. des Nouv. Nes, p. 468. 



198 CONGESTION AND APOPLEXY OF THE BRAIN. 

mand has related the history of one case (set. 3) in his third letter, and 
M. Constant of another (get. II). 1 MM. Sestie' 2 and Cazalis have re- 
corded three, M. Valleix three cases, 3 M. Billard one, and Dr. West 
one case. 4 

But hemorrhage into the brain may be the result of, or at least con- 
nected with ramollissement, and these cases are by no means so rare ; 
for instance, Becquerel met with four such. 

294. It appears that this form of the disease is not limited to any 
peculiar age ; it has occurred as early as three months, but it seems 
more frequent in children after three years. 

The symptoms do not differ very widely from those observed in adults 
laboring under the disease. There may be previous headache, heaviness, 
and drowsiness, or the attack may be sudden, and marked by stupor, 
coma, convulsions, or paralysis. 

The symptoms are more obscure in delicate children, as Valleix has 
remarked ; the stupor and loss of power being present in all. Nor 
does there appear to be any special symptoms indicating whether the 
effusion is into the substance of the brain or the arachnoid. 

Of course, in cases of tubercles or ramollissement, the symptoms of 
these diseases will be present, and those of apoplexy merely an addi- 
tion to them. 

295. Pathology. — When a child dies of apoplexy from excessive con- 
gestion merely, we find, on examining the head, that the scalp is un- 
usually vascular, the sinuses of the dura mater filled with blood, and the 
vessels on the superficies of the brain engorged. Very commonly the 
meningeal vessels participate in the general congestion. I have seen 
the former the size of small leeches, with the blood partly fluid and 
partly coagulated. On slicing the brain, innumerable red spots appear, 
indicating that the vessels which permeate the substance of the brain 
are equally the seat of unusual distension, and even so much so as to 
give a reddish color to the brain. 

296. In meningeal apoplexy, the effusion is into the cavity of the 
arachnoid ; most frequently, according to Cruveilhier, limited to the 
cerebellum, sometimes surrounding the posterior lobes of the cerebrum, 
and occasionally both the cerebrum and cerebellum are covered with 
a layer of blood. Rilliet and Barthez state that it is more frequent on 
the convex surface of the brain. It is very rare that the hemorrhage 
takes place into the ventricles ; however, Cruveilhier met with three 
examples of it ; M. Valleix with one ; and M. Walther has recorded 
another. 5 Still more rare is it for the blood to be effused external 
to the arachnoid, either on the side of the pia mater or the dura mater, 
although I have already (103) mentioned the occurrence of the latter ; 
and I may add that in very young infants who die of apoplexy, it is by 
no means uncommon to find cephalhematoma, or even patches of blood 
effused under the scalp or pericranium, quite independent of local 
pressure. 

1 Gaz. des Hopit. des Enfans, Ap. 1842. 

2 Bull, de la Soc. Anat., 1832. Bull., xlii. p. 331. 

3 Clinique des Mai. des Enfans, p. 575. 

4 Lectures. Med. Gnz.. June 18, 1F47, p. 1062. 

5 Banking's Abstract, vol. iii. p. 159. 



CONGESTION AND APOPLEXY OF THE BRAIN. 199 
<* 

297. The blood effused into the serous cavity presents different as- 
pects, and undergoes different changes, according to the period which 
may elapse after its escape. At first it is, of course, fluid, but about 
the fourth or fifth day it coagulates, the serum is absorbed and gra- 
dually disappears, and the clot becomes adherent to the parietal serous 
membrane, and undergoes an important transformation. A new mem- 
brane is formed, and covers both its surfaces, but the layer on the upper 
surface gradually becomes thinner, until it is closely adherent to the 
serous membrane ; the inferior layer assumes all the character of a 
serous membrane, and is united to the arachnoid at the circumference 
of the clot, giving to the latter the appearance of subserous effusion. 
That this is not the case has been demonstrated by M. Baillarger, who 
has proved that the true serous membrane can be traced behind the clot. 1 

The clot increases in firmness and diminishes in volume by the gra- 
dual absorption of its serum. At first of the usual red color, it be- 
comes paler by degrees, more slowly internally than externally, and at 
length is little more than a thin fibrinous lamella of a fibrous character, 
resembling in appearance false membrane, which has led to its being 
attributed to inflammation. 

In other cases to which I have already alluded the membranes form 
around the clot, and the more solid portion is absorbed, leaving in the 
species of cyst so formed nothing but reddish serum, thus constituting 
a kind of chronic hydrocephalus. 2 

Notwithstanding the large amount of blood thus effused, it is gene- 
rally quite impossible to detect any opening in the vessels from which 
it could have escaped ; we merely find unusual congestion of the arach- 
noid, pia mater, and brain in most cases. 

M. Piedagnel mentions three sources : 1. Fracture and rupture of 
the vessels ; 2. Exhalation ; and 3. A morbid alteration of the arach- 
noid. Although in some few cases the arachnoid in connection with 
the clot is softened, it appears to have occurred subsequently to this 
effusion, and is even more rare than rupture of a vessel. 

Other organs participate in the hemorrhage diathesis also; it is not 
very rare to find ecchymosis, or effusion into the lungs, spleen, intes- 
tines, &c. We do not find the brain either hypertrophic or the con- 
volutions flattened. If the child be young, and the effusion great, the 
cranium expands in proportion ; if it be older, and the effusion great 
death results immediately. 

298. Cerebral apoplexy may present either of two pathological condi- 
tions, first, in the form of innumerable bloody points, the size of pins' 
heads, in the gray and white substance of the brain. These are, in truth, 
small clots, and can be enucleated quite easily ; the brain around them 
may be quite healthy, or it may be softened, and of a white, yellow, or 
red color. The apoplexy may be limited, or it may be diffused through- 
out the hemisphere, giving to it a peculiar spotted appearance. 3 Rilliet 
and Barthez found this capillary apoplexy limited in five cases and dif- 
fused in three. 

1 Bouchut, Mai. des Nouveaux N£s, 466. 

2 Rilliet and Barthez, Mai. des Enfans, vi. ii. p. 39. 

3 Valleix, Clioique des Mai. des Enfans, p. 594. 



200 CONGESTION AND APOPLEXY OF THE BRAIN. 

Or, secondly, the blood may be effused into the substance of the 
brain, and form a coagulum, and this occurs about as frequently as the" 
former kind, and sometimes in combination with it. These apoplectic 
foci are found in various parts of the brain, as in the optic thalami, cor- 
pora striata, and either hemisphere, but in the left oftener than in the 
right, and in the cerebellum not less frequently than in the brain. If 
the case be recent, the blood will be found in a fluid state; but if of 
longer standing, it becomes coagulated, and is imbedded in, but distinct 
from the cerebral substance. When it is connected with ramollissement, 
however, it has the appearance of being mixed with the softened brain, 
and does not, generally, form a distinct clot. Billet and Bavthez relate 
a case of very extensive effusion, which, in some degree, illustrates the 
observation ; and Billard another, of a child who died on the third day 
after its birth, of hemorrhage into the left hemisphere. He found a 
certain degree of softening around the clot, but it would seem to have 
been rather the consequence of the effusion. 1 

299. Causes. — Rilliet and Barthez thus enumerate the causes of apo- 
plexy: "1. The untimely cure of diseases of the scalp; 2. Diseases of 
the sinus of the dura mater ; 3. Compression of the vena cava superior 
by the bronchial glands; 4. Vascular compression, owing to hypertro- 
phy of the abdominal organs ; 5. Cachexia, or general debility, origin- 
ally connected with tubercularization ; 6. Sometimes the hemorrhage 
is primitive, and unconnected with any anterior disease. 2 

In one of M. Valleix's cases, he attributes the apoplexy to the ob- 
struction offered by coagula to the return of the blood. 

In new-born infants, apoplexy may, perhaps, result from some injury 
connected with labor, although we are not able to appreciate it at the 
time, and at a later period to diseases which obstruct the return of the 
blood from the head, as hooping-cough and perhaps disease of the valves 
of the heart. 

300. Diagnosis. — There is so much uncertainty in the symptoms of 
apoplexy in infants and children, sometimes one and sometimes another 
predominating, and most of those which are present occur in other cere- 
bral diseases, that the differential diagnosis is, in many cases, extremely 
difficult. For example : — 

I. Congestive apoplexy may very closely resemble primary convulsions, 
and, in fact, may be no more than an exaggerated form of the same 
disease; but in general we find that the functions of the brain are re- 
stored more completely between the fits in the latter case. In apoplexy, 
on the contrary, the child is drowsy and heavy, or lies in a state of 
stupor or coma. 

II. Meningeal apoplexy may resemble acute meningitis when the effu- 
sion is moderate, or chronic hydrocephalus when considerable, and espe- 
cially when the cyst of serum is formed, as I have mentioned. In acute 
meningitis, the symptoms exhibit more of the character of inflamma- 
tion ; in apoplexy, of compression ; and the incursion of the latter is 
generally more sudden, and the destruction of voluntary power more 
complete; the pulse, too, is less affected, and there is little or no fever. 

1 Mai. des Enfans, p. 600. 2 Mai. des Enfans, vol. ii. p. 63, 



CONGESTION AND APOPLEXY OF THE BEAIN. 201 

Chronic hydrocephalus is of slower development, a series of symp- 
toms generally preceding the enlargement of the head, or those evi- 
dences of compression which present themselves when the sutures are 
ossified; in meningeal apoplexy, on the contrary, symptoms of effusion 
generally precede all others, although some time may elapse before the 
head is perceptibly enlarged. 

in. Cerebral apoplexy, if slight, may be mistaken for an attack of 
convulsions, or of epilepsy, but it will generally be found that the con- 
vulsion is less violent, shorter, and that the patient does not recover 
from it so completely. The stupor, coma, insensibility, and paralysis 
which follow a larger effusion, and the rapidly fatal progress of the 
disease, are quite characteristic, and are in no clanger of being mistaken 
for any other disease, unless, perhaps, the water-stroke. 

When there is simple hemiplegia, we can have but little doubt of the 
case being one of apoplexy, but when convulsions occur, they tend much 
to confuse the diagnosis. 

We should, however, always bear in mind that the diseases with which 
apoplexy may be confounded are much more frequent than the latter ; 
that the causes of the former are generally more patent, and the series 
of symptoms, the whole aspect and physiognomy of the case, are widely 
different to an experienced eye. 

301. Prognosis. — Nothing can be more serious than the prognosis in 
apoplexy. From the congestive form of the disease, no doubt, persons 
who are promptly treated have a tolerable chance of recovery, but me- 
ningeal and cerebral apoplexy almost always prove fatal. There is 
scarcely a case of cure on record, either of primary, secondary, or 
chronic apoplexy, in which any reliance can be placed ; not from defi- 
cient veracity on the part of the writers, but from doubtful diagnosis. 

302. Treatment. — When the case is recent, and, above all, if we have 
reason to believe it one of congestive apoplexy, we should have recourse 
to bloodletting immediately, either from the arm or jugular vein, or by 
leeches. The effect of this proceeding will probably determine the cor- 
rectness of our diagnosis, for if the symptoms have been the effect of 
congestion merely, they will at once be mitigated, and the more alarm- 
ing ones disappear. Judging from the result, we may find it advisable 
to repeat the leeches, and to have recourse to cold applications to the 
head, purgative enemata, small doses of calomel and James's powder, if 
the patient can swallow, and, after a short time, to successive blisters to 
the head or nape of the neck. Should we see any disposition to a return 
of the congestion, in addition to a repetition of these remedies, it will 
be necessary to establish some permanent counter-irritation, either a 
seton or issue, or a perpetual blister on one arm. 

303. If effusion have already occurred, it may be very right to try 
the above remedies, although we shall probably find but little amend- 
ment follow them ; the disease will run its course, nearly unmodified by 
our efforts, and terminate, in the great majority of cases, fatally. 

But should the case be one of meningeal apoplexy, and take on a 
chronic character, distending the cranium, as in the cases described by 
M. Legendre, we shall have an opportunity of trying how much (or 
rather how little) treatment can effect for the patient. For this pur- 



202 PARALYSIS. 

pose we have four remedies of great value, calomel, cold lotions, coun- 
ter-irritation, and purgatives. The calomel should be given in small 
doses, guarded, so as not to affect the bowels too quickly, and should 
be continued until the constitution is affected, as will be evidenced by 
mercurial diarrhoea or soreness of the gums. 

Mercurial inunction may be used, or the blisters dressed with mer- 
curial ointment, for the purpose of more rapidly affecting the system, 
or in case the calomel should excite irritation. 

The hair should be removed, and an evaporating lotion constantly 
applied. 

I have always found that a succession of small blisters acted more 
beneficially than one or two large ones, besides being less liable to ul- 
ceration. I would recommend, then, that we should begin by applying 
a blister to the forehead, then, in a day or two, another to the temple, 
followed by a third on the opposite side, and so on. 

The bowels should at all times be kept free, but after we remit the 
mercury we may try the effect of a brisk purgative occasionally. 

I mentioned before, that, if there should be any sign of teething, the 
gums should be scarified deeply, and all round. 

The diet in all cases should be mild and unstimulating, but in some 
cases a better diet will be necessary, as well as the use of tonics. This 
will depend upon the state of the constitution. 

304. In these latter cases of which I have been speaking, i. e. where 
a large quantity of blood has been effused and separated into its com- 
ponent parts, without an immediately fatal result, Rilliet and Barthez 
recommended that the serum should be removed by puncture, as in 
chronic hydrocephalus. They oppose the practice in the latter disease, 
because the effusion may be connected with tubercular deposits, but in 
meningeal apoplexy they conceive that " nothing but good can result 
from it." 1 



CHAPTER XI. 

PARALYSIS. 

305. 1. Paralytic affections, general, partial or local, particularly 
the latter, though not very frequent, are by no means rare in children. 
That they have not been more distinctly noticed by writers may have 
arisen from their classing them under their various causes, instead of 
regarding them as examples of a special disease. 

The attack presents great varieties as to extent and the accompa- 
nying symptoms : In some cases the upper and lower extremities of 
one side are affected, constituting hemiplegia ; in others both the lower 
extremities, paraplegia : but I am not aware that both the upper ex- 
tremities alone are ever paralyzed. Again, the seizure may be partial, 

* Mai. des Enfans, vol. ii. p. 66. 



PARALYSIS. 203 

loss of power to a great extent, with perhaps a diminution of sensation, 
but not absolute paralysis : or it may be local, affecting a portion of one 
extremity, certain muscles of the face, of the eyeballs, eyelids, or of the 
organs of deglutition, &c. 

Lastly, in any of these cases, the sensibility may be impaired or 
destroyed, or, as we occasionally find, unaltered or even increased. In 
seven out of eighteen cases given by Dr. West, " the leg only was af- 
fected, and in two of these the power over both legs was lost ; in five 
both the leg and the arm were palsied, while in six instances facial para- 
lysis existed. In four of these six cases the paralysis of the portio dura 
was not associated with impaired power over any of the limbs ; once it 
was combined with palsy of the leg and once with general impairment 
of the power of walking." 1 

2. There does not appear to be any age exempt from these attacks ; 
infants at the breast or children of fourteen or fifteen years of age may 
be the subjects of them, but they are perhaps more common from the 
period of the first dentition up to the tenth year. There is some reason 
to believe that in some cases the paralysis is congenital, whether from 
disease in utero, or from pressure during the transit of the infant 
through the pelvis, it is difficult to determine. Professor Robert Smith, 
of this city, brought before the Surgical Society several cases where 
one extremity was not fully developed, and in which there was a de- 
ficiency of cerebral substance in the opposite hemisphere of the brain, 
but whether they ought to be considered as fair examples of paralysis, 
or merely of arrest of development, may be a question. 

Dr. Evory Kennedy, whose experience in the Lying-in Hospital was 
very great, states that " paralysis in the new-born infant is not a very 
unfrequent disease ; it may occur as the effect of injury to the nerve 
in the part paralyzed, or in its course after its transmission through the 
cranial or spinal aperture. Examples of this we have in injuries to the 
portio dura, as in face presentations, or when the head has been long 
pressed against the projecting ischiatic spines. Several cases of this 
kind have occurred to me, in which the disease Avas quite local, the 
paralysis being removed on the subsidence of tumefaction produced by 
the protracted pressure." 2 Inmost cases, however, Dr. Kennedy men- 
tions that the paralysis is connected with cerebral or spinal derange- 
ment ; in some preceded by apoplexy, in others by convulsions, or 
convulsions of the opposite side may co-exist with paralysis. Some- 
times the affected limb was convulsed: in other cases, there was a more 
or less complete paralysis of one side, with a partial paralysis of the 
other. Cases illustrating these varieties are related by the author. 
Leeches, stimulating frictions to the spine, and calomel, appear to have 
been very successfully employed. 

More recently, Dr. Landowzy has published a paper showing that 
facial paralysis may be the result of pressure by the forceps during 
delivery, even though the instrument may have left no marks upon the 
infant ; and he considers that the same result may follow when the 

1 Diseases of Infancy and Childhood, p. 137. 

2 On Apoplexy and Paralysis in New-born Infants, Dublin Journal, vol. x. p. 430. 



204 PARALYSIS. 

pressure is from pelvic tumors or deformity ; and he states that during 
quiescence the face is quite natural, but that when the child cries the 
paralysis becomes evident. He found the disease to cease spontaneously 
after an interval of from a few hours to two months. 1 

Dr. Doherty, in an excellent paper, 2 gives two cases which were 
delivered by the forceps, and in which facial paralysis was observed 
immediately afterwards ; and two other cases, in one of which paralysis 
of the arm and in the other of the muscles of the neck occurred shortly 
after birth. The former was cured by the use of mercurial alteratives, 
continued purges, the douche, and chalybeate tonics. 

There can be no doubt, then, that facial paralysis may be congenital, 
and as little, I think, that more extensive paralytic affections are so 
occasionally. 

Dr. Henry Kennedy has given two cases which he thinks were con- 
genital. One of them he relates as follows : " A child, set. six, was 
brought to me on account of his walking lame. The mother said that 
from the time the child began to walk it had limped ; several medical 
men had seen it, but that it was no better. On examination, the right 
lower extremity was wasted, and its temperature was evidently lower 
than the other. Nothing could be detected wrong with any of the 
joints except that they could literally be twisted in every direction." 3 

Dr. "West also mentions cases, which one can scarcely doubt were 
congenital. 

In all these cases, the growth has evidently been checked and retarded; 
the affected limb has not kept pace in volume or length with the sound 
one, and its power is much inferior. I have a case under my care at 
present somewhat resembling these, but with less loss of power. The 
child, aet. eight, had an attack of endocarditis about five or six years 
ago, from which he recovered, but with injured valor. About two years 
ago, he showed symptoms of lameness, and since that time his leg has 
evidently been checked in its growth, and is now less in volume than 
the other ; but he manages to use it pretty well. 

306. 3. Causes and Symptoms. — Paralysis in infants and children may 
arise either from organic disease of the nervous system ; from pressure 
upon some part of the nervous centres or upon individual nerves ; or, 
lastly, it may be a reflex irritation from some distant part. Let us 
examine the principal varieties shortly. 

(1). No doubt that paralysis in children, as in adults, may result from 
a partial effusion of blood pressing upon certain parts of the nervous 
centres, less in amount than in cases of apoplexy, but sufficient to 
occasion loss of motive power and sensibility in one-half of the body. 
Morgagni, for example, mentions a case of spinal apoplexy which was 
attended with pain and paralysis, 4 and other cases might be adduced. 
They are, however, rare in children. 

(2). When speaking of tumors of the brain and spinal marrow, I 
mentioned that paralysis generally occurs at some period of the disease ; 
at its commencement in a few cases, but generally at a more advanced 

1 British and Foreign Med. Review, vol. x. p. 269. 

2 Dublin Journal, vol. xxv. pp. 82-87. s Med. Press, vol. vi. p. 202. 
4 Epistola 10, Sect. 13. 



PARALYSIS. 205 

stage. It may be partial, the effect of local pressure, or affecting gene- 
rally the motion and sensibility of one side. It is remarkable that 
although the child may recover to a certain extent from the other 
accidents of this disease, the paralysis is in almost every case permanent 
and without mitigation. 1 In Dr. Geoghegan's case there was complete 
paraplegia ; but in Dr. Green's case, certain muscles of the eyeballs 
alone were affected. 

(3). Encephalitis is not unfrequently accompanied with partial or 
general hemiplegia, and this paralysis may be combined with involuntary 
movements of these limbs, or with rigidity. 

When the inflammation ends in softening, we also find hemiplegia 
among its effects, alone or with convulsive movements of the other half 
of the body. In these cases, however, the concomitant symptoms are 
pretty plain, and we shall generally be able to trace the palsy to its true 
proximate cause. 

(4). In abscess of the brain we almost always find paralysis, as in the 
cases I have related in a former chapter from Drs. Bateman and Aber- 
crombie. Such cases, however, are both rare and obscure. 

(5). Chronic softening of the spinal marrow is characterized by par- 
tial or general hemiplegia. There is great general weakness of the 
lower limbs, which the patient can scarcely move. "Sometimes one limb," 
McCalsy observes, " or a portion of it only, is paralyzed. In this 
case, the extremity, or the diseased portion of the spinal medulla, when 
it is only partially affected, is in a state of atrophy, the muscles being 
much softer and smaller than those of the opposite extremity. In 
some cases, when the muscles have continued long in a state of paralysis, 
the antagonist muscles, acting with uncontrolled force, produce a per- 
manent contraction." " On examining the spinal marrow after death, 
we find it in different states of softening, from that almost resembling a 
fluid to that which permits the finger to be pressed upon it, and only 
presents a kind of indentation." 2 

(6). Acute tubercular meningitis, which often commences by a convul- 
sion, not unfrequently exhibits paralysis towards its termination. The 
arm or leg, or both of them, lose power and sensibility, and occasionally 
we see convulsive movements of the opposite extremity. From this 
disease, and especially from the stage at which paralysis takes place, 
patients rarely recover, and therefore the paralysis possesses less prac- 
tical interest for us. 

In some cases of meningitis, when recovery does take place, we find 
remaining a kind of partial paralysis ; for example, one leg will be more 
feeble than the other; the child rather drags it, and complains perhaps 
of its being weak. I have repeatedly observed that children recovering 
from this disease are less able to walk, less sure footed, and more apt to 
trip and stumble over slight obstacles than previous to their illness, indi- 
cations probably of both loss of power and sensibility. 

Squinting, also, which so often remains after this disease, is clearly a 
partial paralysis of the muscles of the eyeball. 

I have also known paralysis of the portio dura remain after an attack 
of meningitis, presenting all its peculiarities, the face natural in repose, 

1 See Dr. J. McCcrmac's paper, May 27, 1843. 2 On Diseases of Children, p. 430. 



206 PARALYSIS. 

but distorted when speaking or excited, mastication natural, &c. This 
case has now remained in the same condition for several years. 

(7). I have already mentioned the paralysis of chronic hydrocephalus. 
In slighter cases we find a diminution of power, but rarely of sensi- 
bility of the lower limbs ; the child may be able to move them, but can 
with difficulty, if at all, stand or walk. In other cases the paralysis is 
observed at an early period, or even from the beginning, and as Dr. 
Bright remarks, the patients lie in bed with their legs bent under them, 
or, as in Dr. Ryan's and Battersby's cases, the child may be nearly de- 
prived of the functions of vision, hearing, taste, smell, and touch, and 
entirely of voluntary motion. In some cases, one leg only is affected; in 
others, the lower half of the body, and occasionally, but rarely, the ex- 
tremities. 

The same thing is observed in spina bifida, which is an analogous 
disease ; the limbs may be of the natural size, but they are deficient in 
power. Generally speaking, the sensibility is preserved, and occasionally 
increased, but I have seen cases in which it was decidedly diminished. 

(8). After convulsions we not unfrequently find a partial weakening 
of the motor power of certain muscles of the limbs or eyeball ; but if the 
child recover promptly from the principal disease, this symptom gra- 
dually disappears. 

(9). When treating of chorea, I observed that in some cases it ter- 
minates in palsy, either in consequence of inflammation or from pressure 
upon some portion of the brain, spinal cord or nerves, which is not un- 
common in that disease. Dr. H. Kennedy has noticed some symptoms 
of chorea in two of the cases of paralysis which he has reported. 

(10). So far the paralysis may be distinctly traced to some pathological 
condition of the brain and its membranes, or of the spinal marrow, of 
which it appears to be the direct result. In most of these cases the intel- 
lect of the child is weakened or totally obscured, and the expression of 
the face corresponds very accurately ; we see either compression, stu- 
pidity, or a fatuous semi-idiotic expression. 

But by far the most numerous class of cases of paralysis in children 
are of quite another kind ; originating in causes which act through the 
excito-motory system of nerves, they present admirable examples of 
reflex irritation. They generally occur in children between the ages of 
one and six years, though sometimes earlier. 2 Of Dr. West's eighteen 
cases, thirteen occurred between eight months and three years of age. 

(11). From the age alone at which the attack occurs, we might at once 
conclude that dentition must be one main cause, and we have evidence 
to prove that it is so in the fact that in many cases the most careful in- 
quiry shows us no other exciting cause, that the gums are much swollen 
and irritated, and that scarifying the gums is often followed by a case 
of the palsy. The attack may arise during either the first or second 
dentition, but is much more frequent with the second, or perhaps it may 
be, as Dr. Heiss has suggested, that the origin is overlooked in young 
infants from their not using their lower limbs 3 

1 Dublin Journal, vol. ix. p. 91, N. S. 2 Underwood, Diseases of Children, p. 2G9. 

3 London Journal of Medicine, Jan. 1850. 



PARALYSIS. 207 

One great peculiarity of these attacks is their suddenness. The child 
may go to bed perfectly well, and during sleep perhaps become uneasy, 
restless, grinding its teeth, or groaning and screaming out suddenly. 
Towards morning, it may be rather feverish, and its head hotter than 
usual. The next day, we find it unable to raise its arm or leg, or 
perhaps an arm and leg, or more rarely both arms or an arm and both 
legs. The affected arm hangs down helplessly, and, from the gravita- 
tion of the blood, the hand and fingers become bluish and swollen, but 
the temperature of the limb is not diminished. The sensibility is 
generally more obtuse than usual, and sometimes entirely lost. No 
pain is felt, but occasionally a sensation of dragging about the shoulder- 
joint. The leg when affected is equally powerless and insensible, and 
now and then the palsy seems to extend itself from the upper to the 
lower extremity. 

Some variation as to the mode of invasion is observed ; the prelimi- 
nary symptoms may be more prolonged, and occasionally the attack is 
ushered in by a convulsion. 

The duration of this form of paralysis is very uncertain. Some 
cases recover after a few days or a week or two, others continue for 
months or years; some appear easily cured, others resist all treatment, 
and in the course of time exhibit symptoms of more serious disease of 
the spinal cord or brain, as dyspnoea, twitching of the muscles, squint- 
ing, perhaps convulsions, or the child falls into a comatose state and 
dies. 

But there is another class of cases, where the disease is not cured, 
or only partially, but the patient does not die. The limb remains par- 
tially or wholly paralyzed, its growth is retarded, and its muscles 
become atrophied, 1 while the rest of the body is fully developed. In 
cases of the upper extremity, the shoulder-joint may be injured. Dr. 
West saw two cases of dislocation, evidently from relaxation of the 
ligaments and the constant weight of the paralyzed arm. 

Dr. Underwood mentions that he has known the sound side to become 
paralyzed, the side previously affected recovering its power. As a 
general rule, the intellect is not enfeebled unless organic disease of the 
brain should be superinduced ; but in some few cases the expression of 
the face would rather denote a feeble state of the mind. 

It is not easy to pronounce upon the exact pathological cause of all 
these attacks. In the majority of cases, no lesion of the nervous sys- 
tem is discoverable, the attack being a reflex irritation simply. And 
even when we find some disease of the brain or spinal marrow, it is not 
always easy to say whether that may be the primary lesion or one that 
has supervened. Dr. Heiss is disposed to attribute the paralysis to 
pressure upon the roots of the brachial nerves from excessive congestion ; 
and he has given a case in which this state of the nerves was found in 
a child who suffered from paralysis and was killed by an accident. 2 

Dr. West states that of his eighteen cases there were but two in 
which the paralysis appeared to be connected with permanent disease 

1 Simpson, Ed. Monthly Journal, Jan. 1851. 

2 London Journal of Med., Jan. 1850. 



2C8 PARALYSIS. 

of the brain ; and in eight out of eighteen cases no indications of cere- 
bral disturbance occurred before the paralysis, or came on afterwards. 

Dr. Coley, whilst regarding the disease as a reflex irritation, observes 
that he has always found " organic mischief either near the pons 
Varolii or in the intestinal or laryngeal mucous membrane as the pri- 
mary cause of the morbid action of the motor nerves." 1 

In two cases mentioned by Rilliet and Barthez, where death was oc- 
casioned by an attack of pneumonia, there was no alteration whatever 
in the brain or spinal marrow. 2 

5. Another more limited and local form of paralysis to which I have 
already alluded, also occurs during dentition. I mean the facial para- 
lysis, or paralysis of the portio dura, and which has also been termed 
Bell's paralysis in consequence of that celebrated physiologist being 
one of the first, if not the very first, to give the true explanation of it. 

It may arise during dentition, with or without any other symptom of 
nervous disturbance, and its peculiarities are so marked that we can 
have no difficulty in recognizing it at once. 

During repose, the countenance has its natural calm and equal aspect, 
both sides being alike and natural ; but if any emotion be excited, or 
the child attempt to speak, the face becomes instantly distorted; the 
muscles of the affected side are passive, whilst those of the unaffected 
side draw the mouth, cheek, and sometimes the eyelid outwards. The 
child can masticate its food as well as other children, but if it should 
get into the pouch of the cheek, he will generally be obliged to remove 
it with his finger, because the buccinator muscle is paralyzed, although 
the temporal and masseter muscles are not. The tongue is not para- 
lyzed, although if the child be desired to put out his tongue, it is pro- 
truded crookedly, yet this is on account of the distortion of the mouth. 
If the angle of the mouth on the paralyzed side be drawn a little out- 
wards by the finger, then the tongue will project straight. 

The eyelids appear weakened and unable to close promptly and com- 
pletely, so that in some cases they seem permanently half open. 

Dr. Watson has drawn the following graphic picture of a patient 
affected with this disease. " The appearance presented by patients 
affected by facial palsy is peculiar and very striking. From one-half 
of the countenance all expression is gone, the features are blank, still, 
and unmeaning. The other half retains its natural cast, except that in 
some cases, the angle of the mouth on that side seems drawn a little 
awry. This is apt to be mistaken for proof of a spasmodic condition 
of that part ; but it is owing simply, as I stated before, to the want of 
the usual balance or counterpoise from the corresponding muscular fibres 
of the palsied side. The patient cannot laugh, or weep, or frown, or 
express any feeling or emotion with one side of his face, while the 
features of the other may be in full play. One-half of the aspect is that 
of a sleeping or of a dead person ; or stares at you solemnly ; the 
other half is alive and merry. The incongruity would be ludicrously 
droll, were it not also so pitiable and distressing." 3 

1 British Record of Obstetric Med., June 1, 1848, p. 189. 

2 Mai dos Eni'ans, vol. ii. p. 336. 

3 Practice of Physic, yoI. i. p. 548. 



PARALYSIS. 209 

This power of paralysis often proves but temporary, the child gradu- 
ally recovering the use of the affected muscles, but in other cases the 
paralysis remains permanently, and it is important to bear in mind that 
it may result from more serious organic mischief. Dr. Graves mentions 
that he has seen it the result of an apoplectic seizure, and he relates a 
case in which it was caused by an abscess of the internal ear, with 
destruction of the tympanum, ossicula, the portio dura, and a part of 
the petrous portion of the temporal bone. 1 

It may occur alone or in combination with palsy of the limbs. During 
dentition, also, we find not unfrequently a partial paralysis of the muscles 
of the eyeball, giving rise to squinting, and in some cases a peculiar 
drooping of the eyelid, so that the child cannot expose the entire eye, 
as in ptosis. As to the curability of paralysis connected with dentition, 
Dr. West informs us that in six only of his eighteen cases was a cure 
effected ; in two of them the portio dura alone was affected ; in two 
others the paralysis of both leg and arm was incomplete and associated 
with a state of general debility, and in two the loss of power in one 
leg had come on after the child had been sitting for some hours on a 
stone door-step. The facial paralysis, when it exists alone, is by far the 
most easily cured, and it is a disease involving no clanger. 

(12). Cold may directly cause paralysis. I have just mentioned that 
in two of Dr. West's cases it resulted from sitting on a cold stone step, 
and such cases are by no means uncommon. Paralysis of one arm has 
come on from lying too long in the grass, and of the portio dura from 
driving in an open vehicle in the teeth of a cold wind. 

(13). From the delicacy of the mucous membranes and the suscep- 
tibility of the nervous system in young children, we cannot be surprised 
that paralysis, as well as convulsions, may be caused by a disordered 
state of the alimentary canal, proceeding from indigestible food, ivorms, 
constipation, §c. Drs. Underwood, 2 H. Kennedy, 3 Doherty, 4 Graves 
and others attribute it to this cause, and Dr. H. Kennedy especially 
where it complicates remittent fever. 

(14). Remittent fever is occasionally followed by paralysis, most fre- 
quently of one of the extremities, of which Dr. Doherty has given a 
case. Whether it is a pure reflex irritation, or proceeds from some or- 
ganic mischief, it is very difficult to decide. Dr. H. Kennedy has given 
three cases, and remarks, that he found them very uncertain as to re- 
covery, some requiring months and others remaining incurable. Sir 
Walter Scott is an illustrous example of the power of the disease. 

(15). In like manner, paralysis may follow scarlatina; when the 
patient becomes convalescent, he is found to have lost the use of an 
arm or a leg. Dr. Kennedy has published a case of this kind, in which 
there existed a bruit de soufflet and slight symptoms of chorea. He 
has also kindly furnished me with another which occurred in the practice 
of Dr. Jabuteau of Portarlington. The child on recovering from scar- 
latina was exposed to cold, and was attacked by anasarca, for which 
diuretics and calomel were exhibited. Very unexpectedly salivation oc- 

1 Chir. Med., vol. i. p. 569. 2 Diseases of Children, p. 269. 

3 Dublin Journal, vol. ix. p. 88, N. S. 4 Dublin Journal, vol. sxv. p. 78. 

14 



210 PAKALYSIS. 

curred, and it was whilst thus relieved from the anasarca, but under the 
ptyalism, that paralysis of the right side occurred. Dr. Simpson also 
mentions similar cases. 1 

(16). But other and some apparently unlikely causes may bring on 
an attack. Sir Charles Bell knew facial paralysis to accompany mumps. 
Dr. Watson mentioned a case in which it arose from a scrofulous tumor 
behind the ear, which was followed by caries of the bone. 2 My friend 
Dr. Stokes informs me that he has seen it connected with a carious 
tooth, with a miL 
the internal ear. 

6. Pathology. — I have incidentally stated nearly all that is to be 
said upon the pathology of this affection. Certain cases, although by 
no means frequent, evidently result from disease of the brain and spinal 
marrow, and the appearances after death will exhibit either hemorrhage, 
inflammation and its consequences, or tumors, as I have described in 
their respective chapters. 

Dr. McCormac attributes it in some cases to spinal concussion or 
temporary injury of the sciatic nerves ; but he does not give any evi- 
dence in support of this opinion. 

In other cases, where an opportunity of making an examination has 
been afforded, no morbid change whatever has been detected, or perhaps, 
as in Dr. Heiss's case, some congestion about the roots of the nerves. 
But our information about the disease is very scanty, as it very rarely 
proves fatal. 

7. Diagnosis. — As a general rule, there will be little difficulty in 
forming a correct diagnosis if we make a careful examination. But a 
superficial inquiry may mislead, and we may attribute the loss of power 
to the injury of a joint, to a blow, or to pressure, instead of regarding it 
as a serious disease. But the absence of pain on moving the limb, or 
examining it, the loss of voluntary power, and the diminished sensibility 
generally, are sufficiently characteristic. 

Another very important question is how to distinguish those cases 
where the palsy results from organic disease of the nervous system from 
those which are reflex irritation merely ? As a general rule, those cases 
where an evident exciting cause exists, such as dentition, cold, &c, may 
be set down as reflex irritation, and this will include a large class ; but 
of the doubtful cases which remain, what are we to say ? I should 
place great value as a guide upon the presence or absence of other 
symptoms, such as startings, wakefulness, partial convulsions, stupor, 
beat of head, quick pulse, &c, provided that no other irritation existed 
which might give rise to them. 

Facial paralysis is almost always a reflex irritation, but I have men- 
tioned an exception which occurred in my own practice. 

Upon the whole, I am inclined to agree with Dr. West, who observes 
that " in many cases the history of the patient will of itself be sufficient 
to guard you from error ; for if paralysis occur suddenly, affecting both 
limbs on one side, and be neither preceded nor attended by any cerebral 
symptom, it is almost certain that it does not depend on serious organic 

1 Ed. Monthly Journ., Jan. 1851. 2 Pract. of Phys., vol. i. p. 555. 



PARALYSIS. 211 

disease of the brain. Our decision will be more difficult if the loss of 
power have been gradual, especially if only one limb be affected ; but 
if the brain be diseased, you will rarely find a mere weakening of the 
motor power ; for connected with it there will usually be occasional in- 
voluntary tremor or twitchings of the limbs, or contraction of the fingers 
or toes. When the paralysis succeeds to convulsions, the case will be 
still more obscure. In most cases of simple paralysis, however, the palsy 
comes on after a single fit; while if it depend on some local mischief in 
the brain, it is generally preceded by several convulsive seizures, during 
each of which the limb that afterwards becomes palsied is in a state of 
perpetual movement, or is sometimes the only part where convulsive 
movements occur." 1 

8. Prognosis. — When the attack originates in organic diseases of 
the brain, the prognosis will depend upon the nature of that disease, 
and upon the general condition of the patient, the paralysis being 
rather an aggravation of the prognosis. Upon these subjects I have 
entered fully in the respective chapters. 

This paralysis, which is the result of reflex irritation, is rarely fatal, 
but it may impair the usefulness of the limb for a long time, and 
entail its comparative inferiority to its fellow for life. 

Facial paralysis involves no danger of itself, though it often proves 
tedious and sometimes incurable. 

Dr. West thus sums up the results in his eighteen cases : " in only six 
of the eighteen did a cure of the palsy take place;" "in four of these cases 
the treatment was commenced within two or three days after the occur- 
rence of the paralysis, and continued uninterruptedly until the patient's 
recovery. In one the treatment was begun after the lapse of three 
weeks ; and in another, though begun immediately, it was discontinued 
for some weeks. In four instances partial improvement took place, 
and there seems reason for anticipating that in one, this improvement 
Avill go on to complete recovery. In two the improvement was but 
slight ; in both these cases, however, there was more serious cerebral 
disease than in any others. The treatment of another was continued 
out for a week, and though the child gradually recovered power over 
the arm, yet the leg remained quite useless. In the other three cases, 
treatment was begun within a few days, and was continued without 
interruption. In eight cases, in which no treatment was adopted, or 
not till after the lapse of a period of six months, no improvement took 
place in the patients' condition." 

9. Treatment. — I shall not now allude to the treatment of those 
cases which depend upon organic disease of the brain, but refer my 
readers to the different chapters upon these diseases. 

The facial paralysis which results from the use of instruments, or 
from pressure, requires but little treatment ; it subsides spontaneously 
in many cases ; and in others its disappearance may be assisted by 
fomentations to the part upon which pressure has been made. 

In facial paralysis at a later period, after removing every possible 
cause, scarifying the gums thoroughly, clearing out the bowels, &c, 

1 Diseases of Infancy and Childhood, p. 140. 



212 PARALYSIS. 

it is advisable in many cases to apply a leech or two to the neighbor- 
hood of the portio dura, near where it emerges from the skull. 

Small blisters are also of use, and I think benefit will be derived from 
painting the part with tincture of iodine, or rubbing in the ointment 
of the hydriodate of potash. 

Dr. Watson advises that mercury should be given so as just to touch 
the gums, and for a valid reason: "I always take the latter precaution, 
lest any effusion of lymph should cause abiding pressure on the nerve." 
He, however, is rather speaking of adults, and we must not forget that 
this effect is not so easily produced in children, and we may, I think, rest 
satisfied with giving a certain amount of mercury, especially if mercu- 
rial diarrhoea be produced, even though the gums be unaffected. 

The constitution must also be carefully attended to, the bowels regu- 
lated, a purgative given occasionally and tonics if necessary. I agree 
with Dr. West, that preparations of iron answer better than other tonics. 

When the paralysis affects the limbs, the treatment should be directed 
to the spine, or near to the place whence the nerves affected issue from 
the spinal canal. Frictions to the limbs, stimulating applications, &c, 
which are so commonly employed, are of little use, as they do not go 
near to the root of the evil ; they may quicken the circulation and pre- 
serve the heat of the limb, and when the disease is subsiding, may per- 
haps assist in restoring muscular tone, but no more. Cupping or leeches 
near the spine, especially if we have reason to believe that there is any 
congestion ; l or where the disease is more chronic, blisters or irritating 
liniments seem to afford the best chance of relief, but they not unfre- 
quently fail. Purgatives, not severe ones, and tonics seem to be of 
more use than anything else. Dr. H. Kennedy speaks favorably of 
turpentine in doses of a few drops three or four times a day. 

Electricity has been tried, but the results have not been equal. Dr. 
West has found it rather uncertain. Dr. Simpson has known it to fail. 
Dr. Stokes is strongly impressed with the value of electro-galvanism, and 
he has found electro-puncturation very successful, but the latter could 
hardly be used with young children. 

In chronic cases, strychnine may be cautiously tried in very minute 
doses, say from ^ to g 1 ^ part of a grain three times a day to a child of 
three years old, very gradually increasing the dose, but it will require 
great watchfulness, and an immediate suspension of the medicine if 
twitching and starting of the muscles be produced. In one case in which 
Dr. West gave it and at the same time applied a blister, the child seemed 
much benefited. Dr. Coley quotes two cases in which it was remarkably 
useful; he recommends the thirtieth part of a grain every eight hours 
to an infant six or eight months old, and about the twentieth part of a 
grain to a child two or three years of age ; the dose to be gradually in- 
creased if convulsive twitchings are not observed after a few days. He 
recommends a purgative in most cases before commencing the strychnine. 
The list of remedies we see is not extensive, nor is their successful 
action at all certain, but the chances of success are greater when we 
see the child shortly after the attack. 

1 Heiss, Loncl. Jouru. of Med., Jan. 1850. 



SECTION II. 

DISEASES OF THE RESPIRATORY SYSTEM. 



CHAPTER I. 



I. INTRA-UTERINE DISEASES. — II. CORYZA. — III. EPISTAXIS. 

307. Considering that the respiratory apparatus is not used during 
foetal life, we might naturally expect that it would escape disease ; but 
it is not so. Billard and Cruveilhier observe that in the bronchial 
tubes we find concretions, polypous masses, and evidences of inflamma- 
tion ; and the latter mentions a case of death immediately after birth, 
in which the bronehi were filled with a thick mucus, apparently the 
result of chronic catarrh. 

Examples of lobular pneumonia are recorded by Cruveilhier ; of san- 
guineous effusion, by Mende, Wrisberg, Joerg ; of abscess in the lung, 
by Koelpin, Mende, and Cruveilhier ; of pleurisy, by Veron, Billard, 
Orfila, and Cruveilhier ; of tubercles, by Husson, Chaussier, Cruveil- 
hier, Lobstein, and Billard; of scirrhus, by Wrisberg; of oedema of 
the lungs, by Zierhold ; and of hydro-pneumonia. 1 

II. CORYZA. 

308. Nasal catarrh, or, as it is commonly called, "snuffles," is a very 
common affection among infants, and very troublesome so long as the 
infant is at the breast, because the nose is obstructed, and of course, 
when sucking, the child is not able to breathe through the mouth. 

The attack commences by frequent sneezing, with a snuffling sound 
in breathing through the nose. We are not, however, to suppose that 
because a very young infant sneezes often it has necessarily taken cold; 
the impression of light upon the branches of the fifth pair of nerves 
distributed to the eye, naturally gives rise to sneezing. 

At first there is but little discharge from the nostrils, in a short 
time a secretion of a thin mucus takes place, sometimes acrid and irri- 
tating; and ultimately of an abundant, thick, muco-puriform fluid. The 
mucous membrane is unusually vascular, and peculiarly irritable and 
tender, and after the first stage the sense of smell is lost for a time. 
The voice, too, is changed to that tone which is popularly expressed by 

1 Graetzer Die Krankheiten des Fotus, pp. 1G3, 169. 



214 CORYZA. 

" speaking through the nose." The eyes are in general suffused and 
■watery, sensitive to light, and there is more thirst than usual. 

Some degree of feverishness is present, the infant is uncomfortable, 
heavy, and cross, the skin is hotter than usual, and perhaps, but not 
necessarily, the pulse maybe quicker. 

If the child be old enough, it will complain of heat and soreness of 
the nose, of some headache in the region of the forehead, and probably 
uneasiness in the back and limbs, if it be very feverish. 

The attack is at its height about the third or fourth day, after which 
the feverishness disappears, the discharge diminishes, becoming more 
viscid and yellow, and the difficulty of breathing through the nose 
ceases. It is very liable, however, to be reproduced by any exposure 
to cold. 

309. This is the simple and ordinary form of catarrh of the nasal 
mucous membrane. Drs. Denman and Underwood, however, describe 
a much more serious variety, which presented itself to their notice for 
the first time in the summer of the year 1790. It was characterized 
by a thick, puriform discharge, great, but not constant difficulty of 
breathing through the nose, at times requiring an attendant to watch 
the child and to keep its mouth open. A curious purple streak was 
observed at the verge of the eyelids, which Denman considered pathog- 
nomonic, and in most cases a fulness about the throat and neck exter- 
nally. After the symptoms had continued for some days, the infant 
became feeble and languid, and upon looking into the throat " the ton- 
sils were found tumefied and of a dark red color, with ash-colored 
specks upon them, and in some there were extensive ulcerations." The 
patients " gradually declined in strength, and had a peculiar catch in 
respiration, as if the velum pendulum palati were elongated. They 
were unable to suck, though not universally ; swallowed with difficulty 
whatever was given in a spoon ; and died in convulsions, or with all the 
marks of great debility, though not on any particular day of the dis- 
ease." 1 

Dr. Denman met with eight cases in eight months, six of whom died. 
One of them was examined, but no internal organic disease was dis- 
covered ; and the affection seems to have been an intense inflammation 
of the entire Schneiderian membrane, with great constitutional debility, 
and accompanied with disorder of the stomach and bowels, as the stools 
were thick and pasty, and of a green or blue color. 

Billard also speaks of a severe form of coryza, accompanied with 
exudation of lymph, and proving fatal. 

I shall notice the syphilitic coryza by and by ; it seldom constitutes 
the sole symptom, and its true character will be determined generally 
by the concomitant symptoms. 

310. Causes. — In very young infants it is owing to cold taken in 
washing, or by undue exposure — the great transition from the warm 
temperature of uterine life to the severe and changeable atmosphere of 
extra-uterine existence rendering the infant peculiarly susceptible. It 
also accompanies certain other diseases, as the exanthemata, and in 

1 Underwood on Diseases of Children, p. 175. 



EPISTAXIS. 215 

these countries prevails epidemically during winter and spring, but 
affecting chiefly infants of more advanced age. 

311. Treatment. — When it exists simply, and is not a symptom of 
a more general affection of the mucous membrane, but little treatment 
will be necessary. A dose of purgative medicine, with warm baths at 
bedtime for a few nights, will relieve the feverish symptoms and head- 
ache ; and a gentle diaphoretic mixture may be given at intervals 
through the day. 

It is very necessary to do something for the relief of the local com- 
plaint, on account of the distress of the infant, and I have found the 
best thing to be fomentations, by means of a hollow sponge dipped in 
hot water, and squeezed nearly dry, and then laid on the nose and 
forehead. The vapor of the water is thus applied both internally and 
externally, and is very soothing. After this we may adopt the popular 
remedy of greasing the nose externally, which I know by experience to 
be very useful, although I am quite unable to explain why. [Dr. Chas. 
D. Meigs recommends the application of a flannel cap to the infant's 
head, and to be worn until the affection yields. In children subject to 
this annoying disease, I have succeeded in obviating a constant recur- 
rence of attacks by adopting Dr. Meigs's mode of treatment.] 

These measures will apply equally to infants and children : but with 
the former, if the nose be quite obstructed, it will be better to sub- 
stitute food for nursing two or three times in the day; and with the 
latter, if there be much fever, low diet for a few days will be advisa- 
ble. 

When the coryza forms but a portion of a more general attack, the 
proper remedies for the more serious disease will be beneficial, and, in 
addition, we need only use the fomentations. 

In the more serious variety described by Dr. Denman, he found great 
benefit from repeated purgation by castor oil, and some cordial, as 
Dalby's carminative, with the exhibition of the decoction of oak bark, 
if the discharge continue long. 

Blisters are inadmissible, for in some cases in which they had been 
applied, he found the surface ulcerated and sphacelated. 



III. EPISTAXIS. 

812. Bleeding from the nose is by no means uncommon with children 
of all ages, but it is generally very moderate, and, when primary, never 
to such an extent as to endanger life. M. Valleix, who has analyzed a 
great number of reported cases, has not found a single example of pri- 
mary nasal hemorrhage to this extent, and the researches of MM. 
Rilliet and Barthez confirm his conclusion. 1 

Secondary epistaxis is not unfrequent in children, and is more serious 
in its effects. It occurs in purpura hemorrhagica, in the course of 
eruptive fevers, intermittent typhoid fevers, in hooping-cough, &c. &c. 

M. Latour relates an example occurring during the access of quartan 

1 Mai. des Enfans, vol. ii. p. 28. 



216 SPASM OF THE GLOTTIS. 

ague, and which compromised the life of the child. Rilliet and Bar- 
thez mention a case of very considerable hemorrhage which occurred 
in an infant, attacked with anasarca consequent upon nephritis, and 
many other cases are upon record. 

We have all, probably, witnessed cases of epistaxis occurring during 
hooping-cough, and during an attack of purpura,' the hemorrhage is oc- 
casionally sufficient to destroy life. 

313. In general there can be no difficulty in the diagnosis of the dis- 
ease. The escape of the blood externally marks its source ; but it some- 
times happens that it may proceed from some vessel situated high up 
the nostril, and after it has ceased to flow externally it may gradually 
dribble into the back part of the nasal fossa and pharynx, and then, 
being swallowed and rejected by vomiting, it may be supposed to have 
its origin in the stomach. The only way of deciding this question is 
by carefully examining the pharynx, to ascertain if any blood be still 
escaping, and if so, we can no longer doubt the source of the blood 
vomited. 

314. Treatment. — When the amount of this discharge is neither too 
great nor too often repeated, the effort may be salutary rather than in- 
jurious, and in such cases we shall not need to interfere. 

Should direct treatment be necessary, the best local applications are 
cold lotions to the forehead and nose, counter-stimulants to the extremi- 
ties, astringent injections (such as decoction of matico or oak bark, &c), 
and, as a last resource, the plug. 

In many cases of secondary epistaxis, however, there is some morbid 
alteration of the blood, and the disease which has given rise to this will 
claim our predominant attention ; that being relieved, the epistaxis, like 
the other symptoms, will disappear. It may, however, for present re- 
lief, be proper to have recourse to some of the local applications just 
named. 



CHAPTER II. 

SPASM OP THE GLOTTIS. — THYMIC ASTHMA. — LARYNGISMUS STRIDULUS. 

315. Much confusion has arisen concerning this disease, from the 
use of names, which, to say the least, are inaccurate, and some of which 
convey altogether false ideas of its nature. Thus it has been called 
"Millar's asthma," "Kopp's asthma," "thymic asthma," "suffocative 
catarrh," " false croup," " spasmodic croup ;" " cerebral croup ;" whereas 
it has no affinity at all either to asthma, catarrh, or croup. 

The complaint which is characterized by crowing inspirations, occur- 
ring at intervals, and repeated irregularly but frequently, appears, at 
first sight, to be a simply local affection, but upon close investigation 
will be found to have a deeper origin and a more important character. 
It is not unfrequent in Great Britain and Germany, but very rare in 
France, as Barrier, Rilliet and Barthez, are mainly indebted for their 



SPASM OF THE GLOTTIS. 217 

descriptions to British or German physicians. Drs. Stewart and Con- 
die speak of it as common in America. 

It occurs in infants of from a few months or even days to three or 
four years old. Dr. Copland limits it to between three and four years 
of age. Dr. James Reid to the period of dentition. However, Dr. H. 
Ley saw one case at four or five years old, and another between six and 
seven, and Mr. Porter one at nearly six years of age. Dr. Jas. Reid saw 
a case of this disease in an infant two days old, and heard of another in 
an infant a few hours after birth ; Sir H. Marsh mentions one three 
days, and Dr. Underwood one fourteen days after birth. M. Blache 
found it most frequent from four months to a year, and Guersent from 
one year to six ; but in these countries it is uncommon at the latter age. 
Most of the German writers state that it is most common between the 
age of three weeks and eighteen months, but especially between the 
fourth and tenth month. 

316. The first record we have of the disease, I believe, was in 1761, 
by Dr. Simpson, who termed it " the spasmodic asthma of infants." A 
few years afterwards Dr. John Millar described it (in 1769), and from 
him it was called Millar's asthma. Dr., Rush, of Philadelphia, followed 
him in 1770 (in the Philadelphia Gazette), and both he and Dr. War- 
burton, in 1809, and Dr. Hamilton in 1813, give a fair account of it. 
But by far the most complete description of it is given by Dr. John 
Clarke, in 1815, under the title, "A peculiar species of convulsion in 
infant children." "The child," he says, "is suddenly seized with a 
spasmodic inspiration, consisting of distinct attempts to fill the chest, 
between each of which a squeaking noise is often made. The eyes 
stare, and the child is evidently in great distress ; the face and the ex- 
tremities, if the paroxysm continue long, become purple ; the head is 
thrown backward, and the spine is often bent as in opisthotonos ; at 
length a strong expiration takes place, a fit of crying generally suc- 
ceeds, and the child, evidently much exhausted, generally falls asleep." 1 

There appears to be a considerable resemblance between this disease 
and the very rapid form of hydrocephalus described by Dr. Munro, 
which I have formerly noticed. 

Dr. Golis also alludes to this affection, and includes it among the 
predisposing causes of hydrocephalus. He speaks of it as " a peculiar 
disorder of respiration, in which infants, after a sudden waking out of 
sleep, or from terror or anger, often, without any cause, are suddenly 
seized with a deep, shrill respiration, which for many seconds, sometimes 
even for minutes, threatens suffocation. The whole body becomes stiff; 
the face, hands, feet, and particularly the fingers and toe nails, black or 
blue ; and the little patients lose their breath and consciousness ; at 
length, however, with a cry of alarm, they again recover both.'' 

Dr. Underwood evidently embraces spasm of the glottis in that mys- 
terious term, "inward fits," which, he says, is occasionally accompanied 
"with a peculiar sound of the voice, somewhat like the croup," with a 
quick breathing at intervals. 2 

1 Commentaries on the Diseases of Children, p. 87. 

2 Diseases of Children, p. 181. 



218 BPASM OF THE GLOTTIS. 

Dr. Chcync thus describes the disease in his work on hydrocephalus : 
"It begins with crowing inspiration, like that which takes place at the 
Commencement of a paroxysm of pertussis. At first there are long in- 
tervals between the spasmodic inspirations (several days, perhaps), as 
they appear to be connected with a disordered stomach and the absence 
of bile in the bowels — to arise from sudden exertion or fits of passion ; 
and as the child often continues to thrive notwithstanding, the disease 
is not much attended to." 

Very valuable monographs on this affection have since appeared by 
Dr. II. Davies, Mr. Pretty (cerebral croup), M. Roberton, Dr. Mont- 
gomery (thymic asthma), Mr. Hood, Sir Henry Marsh (spasm of tho 
glottis), Dr. Jas. llcid, Dr. Ley (laryngismus stridulus), (infantile 
laryngismus), MM. Tilache, Gucrsent, Kopp, Ilirsch, Kyll, Caspar, 
Fricke, Oppenheim, &c, and it is noticed in almost all the systematic 
treatises. 

817. Symptoms. — The disease appears, then, to consist essentially 
in a, spasmodic closure of the rima glottidis and larynx, terminating by 
a forced inspiration, rather than in a spasmodic inspiration, as Dr. 
Clarke supposed. 

In the milder cases there are no premonitory symptoms ; the attack 
occurs quito suddenly, perhaps on first awaking out of sleep, sometimes 
even during sleep ; after a full meal, or whilst at play, or in a fit of 
passion. 

In other cases the attack has been preceded for some days by slight 
wheezing respiration, and an occasional cough, then suddenly the spasm 
occurs. 

Lastly, I have seen spasm of the glottis superadded to general con- 
vulsions, commencing subsequently, and continuing after they had 
subsided. 

318. Whether there be preliminary symptoms or not, the muscles of 
the glottis and larynx are first affected ; tho child is suddenly startled 
by finding that it cannot breathe ; it struggles violently, becomes red or 
even purple in tho face, tho eyes are injected and suffused, tho eyeballs 
protruding, the hands clinched, the head thrown back, and tho wholo 
body agitated with distress and fright, presenting tho aspect of one in 
imminent danger of suffocation. This state lasts generally for a minuto 
or two, and at length, after many fruitless attempts, by a vigorous 
effort, or owing to relaxation of the spasm, inspiration is effected with 
a loud crowing sound, resembling the whoop of pertussis. A good fit of 
crying generally succeeds, and then tho child, exhausted by tho fright 
and struggles, falls asleep. 

In some rare cases the countcnanco remains pallid, though not less ex- 
pressive of anguish and fear. M. Kopp has remarked that in many cases 
tho tongue is protruded during the paroxysm, and that even during 
tho intervals there is a similar tendency. M. Ilirsch mentions that tho 
urine and feces arc often discharged involuntarily during a paroxysm. 

I have mentioned that tho hands arc clinched during the paroxysm, 
as a portion of the general muscular effort ; but if wo observe carefully, 
wo shall find that tho remarkable spasm of the thumbs and great toes, 
described by Dr. Kcllic, is present ; tho thumbs are spasmodically con- 



SPASM OF THE GLOTTIS. 219 

tracted, and thrown across the palm of the hand ; the toes are bent 
towards the solo of the foot, and both wrists and feet are rigidly bent 
downwards and somewhat inwards. The backs of the hands, wrists, and 
feet appear swollen. This local spasm may continue in a slighter 
degree after the spasm of the glottis has subsided, the duration of 
each attack of difficult inspiration is generally about half a minute or 
a minute ; but Dr. Condie mentions their lasting fifteen or thirty. 1 

Dr. Jas. Reid has described four forms of the disease which differ 
merely in intensity, from the slight catching of the breath, the decided 
spasmodic breathlessness with carpo-pedal spasm of the second up to 
the general convulsions of the third, and the complete asphyxia of the 
fourth form. 

319. At the commencement of the disease, especially in the milder 
cases, the spasms occur at distant intervals, perhaps once in the day, 
or with some days' intermission, increasing in frequency and in severity, 
unless checked. 

In severe cases, the paroxysm may occur many times in the day. 
I have known it repeated thirty or forty times ; and in such cases, 
although the spasm is at first confined to the muscles of the glottis and 
larynx, yet, if the disease be neglected or mismanaged, the spasmodic 
action is extended to the extremities, and may terminate in a general 
convulsion, as Sir II. Marsh has observed. 2 

During the intervals the child appears pretty well, but pale, exhaust- 
ed, and irritable, if the fits are frequent. There is no fever, the pulse 
is quiet, the tongue clean, the appetite pretty good, and in many cases 
the bowels are regular. In others, as Dr. Cheyne remarks, there is 
evidence of biliary and gastric derangement. The respiration is much 
as usual between the paroxysms, provided they are not very frequent. 
In the worst cases I have seen it was very hurried. 

When the disease is complicated with dentition, intestinal disorder, 
or general convulsions, of course the constitutional symptoms will be 
more marked ; there will be a quick pulse, loaded tongue, pale flabby 
skin, hurried respiration, and unhealthy evacuations. 

The spasm may return at very uncertain and unequal intervals, as I 
have said, and without any apparent cause, or the very slightest. 
Trivial irritation or annoyance, contradiction, sudden noises, are quite 
sufficient to provoke a return. Sir II. Marsh mentions that the smell 
of new paint always reproduced it in one of his patients. 

320. Dr. II. Davis states that, in all the cases he had lately exam- 
ined, the tonsils were enlarged, the fauces puffy and swollen, and the 
uvula elongated ; but as these symptoms have not been observed by 
other writers, it is possible that the cases may have been complicated 
with this affection. He mentions also that in one case there was obsti- 
nate constipation, with dysuria, and that every attempt to evacuate the 
bladder brought on the spasm. 3 

To another symptom which has been occasionally observed consider- 
able importance has been attached, from its correspondence with a 
pathological condition to which the disease has been attributed. I al- 

1 Diseases of Children, p. 347. 2 Dublin Hosp. Reports, vol. v. p. G18. 

3 Underwood ou Diseases of Children, p. 187. 



220 SPASM OF THE GLOTTIS. 

lude to a swelling of the thyroid and thymus glands. Dr. Montgomery 
mentions a case in which he observed this enlargement, and by direct- 
ing his treatment to this point the child was cured. 1 In four cases, Dr. 
Ley observed a swelling extending from the jaw to the sternum, and 
laterally parallel to the clavicles. Just in proportion to the reduction 
effected in this enlargement, was the diminution of the spasm of the 
glottis and the other symptoms. 

This enlargement, which would be a most important symptom if gen- 
eral, has not been very commonly observed. One cannot doubt the 
accuracy of those who have mentioned it; but, to have the significance 
they have attributed to it, it should have been far more frequently 
noticed. 

821. The duration of the disease, as well as its termination, is very 
uncertain. It may continue a few weeks, and then cease spontaneously, 
or in consequence of suitable treatment ; or it may persist longer, and 
subside after the cutting of some teeth, or from long-continued treat- 
ment. A considerable number of cases run either of these courses, and 
terminate favorably. 

Others, however, prove more serious and end fatally, either suddenly, 
during the first attack, or during a fit subsequently ; or they die after 
a longer illness, in convulsions, or worn out by continual distress. 

It has been suggested that fatal spasm of the glottis may be the cause 
of the sudden deaths, without any apparent cause, that are met with 
among children. Such cases are recorded by Maunsell and Evanson, 
Montgomery, Jas. Reid, and very many writers. The infant may be 
perfectly well, or perhaps only slightly indisposed, when in a moment 
it falls back dead, as happened to the infant of a friend of mine. 

I confess that I am inclined to believe that many of the deaths at- 
tributed to the nurse or mother overlaying the child, are, in truth, cases 
of sudden death from spasm of the glottis. 

322. Pathology. — As one might expect in a disorder which is but a 
symptom, the appearances on dissection present great variety, according 
to the other diseases with which it may happen to be complicated. 

For instance, in many cases, no appearance of disease whatever, in 
any organ, could be detected. 2 In others, the cranium is large and 
imperfectly ossified, the mass of the brain large and rather soft, 3 or 
there have been found tumors in the brain, congestion, and effusion of 
serum, effusion of blood into the cranium, partial closure of the rima 
glottidis, open foramen ovale, congestion of the lung, congestion of the 
glands at the root of the lung, enlargement of the bronchial glands, of 
the thymus gland, of the mesenteric glands, and disease of the intes- 
tines, but no one morbid change is found in the majority of cases. This 
has given rise to an equal variety of opinions, but the very absence of 
morbid phenomena is a sufficient answer to some of them ; as, for ex- 
ample, it is thus proved not to be of the nature of croup, as supposed 
by Underwood, Ferrier, Hecker, Albers, &c, or of asthma, as stated by 

1 Dublin Journal, vol. ix. p. 439. 

2 Sir H. Marsh, Dublin Hospital Rep., vol. v. p. 616. 

3 Dr. Shoepf-Merci, Edin Journal, Not. 1850. 



SPASM OF THE GLOTTIS. 221 

Millar and others, because none of the post-mortem appearances of either 
are ever found. 

Dr. John Clarke regards it as a convulsive affection, depending upon 
diseased action of the brain, and induced by over-feeding, the sudden 
cure of ophthalmia, suppression of cutaneous eruptions, &c. ; and he 
found congestion of the vessels of the brain, water in the ventricles, 
and mesenteric disease. 1 

Dr. Cheyne has no doubt that the brain is really the seat of the dis- 
ease, although the precise morbid condition has not been ascertained. 
He had seen twenty cases, of which one-third were fatal, and he has 
given descriptions of these cases : in the first there were two scrofulous 
tumors imbedded in the brain ; in the second, the convolutions were 
obliterated, and the substance of the brain unusually firm (hypertrophy 
and induration) ; in the third, congestion and serous effusion. 

Dr. Merriman could detect no cerebral disease in two children who 
died during the paroxysm. He found a collection of enlarged glands of 
the neck pressing upon the par vagum. 

Gardien regards the disease as a spasm of the diaphragm, and of the 
muscles of the chest and larynx. 

The name "cerebral croup," given to it by Mr. Pretty, sufficiently 
expresses his view of its nature. Kyll attributes it to inflammation of 
the cervical portion of the medulla spinalis, or to enlargement of the 
cervical and thoracic glands compressing the pneumogastric nerve. 

323. As early as 1723 it was attributed to enlargement of the thymus 
gland by Richa, and in 1726 by Verduis. This view has been revived 
in late years by Kopp, who published a work on the subject in 1830. 
He found the trachea and larynx healthy, the tongue large and thick at 
the root, and the body generally exhibiting marks of suffocation ; but 
the most remarkable post-mortem appearance was the state of the 
thymus gland : " In one case it might have been mistaken for the lung, 
it was so thick and hypertrophied ; it extended from the thyroid gland 
to the diaphragm, was two inches wide, weighing more than an ounce, 
and pressing strongly against the trachea ; on cutting into it there 
flowed out of its whole tissue a quantity of milky fluid. In another post- 
mortem the thymus was found occupying the whole of the anterior part 
of the chest, and forming, with the superior part of the thorax, adhe- 
sions that could be removed only by the scalpel ; it was united to the 
thyroid gland by thick cellular tissue. By the thymus covering the 
whole heart, the sounds of that organ had been intercepted during life. 
The lobes of the gland were elevated and enlarged : its parenchyma 
presented no trace either of suppuration or tubercles, or any other de- 
generation ; on pressure being applied, there came away an abundant 
milky humor, like the spermatic liquor in consistence." 2 

Dr. Hirsch published five cases ; three proved fatal, and in two there 
was a post-mortem examination : "The thymus of the first of these occu- 
pied all the anterior mediastinum, and was composed of two large lobes 
besides several smaller ones. An appendix of the gland arose about its 

1 Commentaries on Diseases of Children, p. 90. 

2 Dublin Journal, vol. ix., p. 514. 



222 SPASM OF THE GLOTTIS. 

middle, and surrounded the common jugular vein ; the glandular paren- 
chyma was firm, and weighed nine drachms and a half. The thymus 
of the second child was not so thick nor of so close a texture ; it ex- 
tended from the thyroid gland beyond the pericardium, which it covered ; 
it had contracted adhesions with the arteria innominata and right caro- 
tid, and its weight was six drachms six grains." 1 

It may be as well to mention here that the thymus gland, in its 
normal state, weighs about half an ounce, or six drachms, and extends 
from the thyroid gland into the upper part of the thorax, lying over 
the pericardium, lungs, and roots of the great vessels. 

Dr. Kornmaul mentions a thymus gland weighing fourteen drachms ; 
Dr. Hirsch one weighing nine and a half drachms ; and Dr.' Van Velsen 
one weighing nine drachms. 

Dr. Montgomery mentions that in two cases the gland was enlarged, 
one of which, he feels assured, weighed two ounces. 2 

On the other hand, the researches of Caspari, Pagenstecker, Rosch, 
Fricke, Oppenheim, &c, led to the conclusion that the disease did not 
depend upon enlargement of the thymus. The latter physician found 
the plexus choroides full of blood, effusion into the chest, glottis erect, 
and the rima open ; no swelling in the neck, thymus gland much as 
usual, perhaps rather heavier, but not corresponding to the description 
of Kopp and Hirsch, and neither pressure nor displacement of the par 
vagum nor recurrent. 

Dr. Roberts mentions five cases of enlarged thymus gland, and the 
editor of the New York Medical Journal two, in which the accompa- 
nying symptoms were not those of spasm of the glottis, but of pneu- 
monia. 

Sir H. Marsh seems to think that the seat of the irritation may be 
at the origin of the pneumogastric nerve. In one post-mortem exami- 
nation which he mentions there was found effusion into the ventricles, 
but no other trace of the disease ; in another, contraction of the rima 
glottidis, engorgement of the right lung and erosion of the mucous mem- 
brane of the stomach ; but in neither is any enlargement of the thymus 
mentioned, and the author is far too acute and careful an observer to 
have overlooked it had it been present. 3 

M. Trousseau refers the disease to a spasmodic condition, with a want 
of harmony in the action of the respiratory muscles ; and he states that, 
during the six years he has been at the head of his hospital, he has 
never met with a single case of thymus sufficiently enlarged to occasion 
the slightest inconvenience. 

Dr. Hugh Ley attributes the disease to a suspended or impeded state 
of the functions of that portion of the eighth pair, which is distributed 
to the larynx, caused by enlarged cervical or thoracic absorbent glands, 
but not from enlarged thymus. 4 

324. I have thus given a cursory glance at the chief of the 'post- 
mortem observations, upon which the different views of the pathology of 
the disease have been founded. These views may be divided into, 1, 

1 Dublin Journal, vol. ix. p. 517. 2 Ibid., p. 433. 

3 Dublin Hosp. Rep., vol. v. p. 515. 4 On Laryngismus Stridulus, p. 113. 



SPASM OF THE GLOTTIS. 223 

those which adduce the evidence of irritation in the central nervous 
system ; 2, those which attribute the affection to pressure upon some 
particular nerves ; and 3, those which look to the enlargement of the 
thymus gland as the "fons et origo mali." Let us examine the two 
latter views a little more closely. The advocates of the last-named 
hypothesis generally consider that the enlargement of the thymus, from 
engorgement, acts mechanically, by pressing upon the larynx and 
trachea, and obstructing respiration ; that relief is afforded, and a ces- 
sation of the paroxysm effected by the diminution of the congestion ; 
and the cure completed by the reduction of the gland to its normal size. 

Dr. Montgomery mentions three ways in which enlargement of the 
gland may occur : 1, either as simple hypertrophy ; 2, comparative 
hypertrophy, when there is a disproportion between the size of the gland 
and the capacity of the upper part of the chest ; or 3, as the result of 
disease ; and he thus explains its modus operandi in producing spasm 
of the glottis : " Supposing any cause to occur capable of producing 
agitation or strong mental excitement in the child, and that the gland 
has been previously enlarged and capable of great distension, a number 
of circumstances will occur which combine in rendering that distension 
still greater, and increasing the size of the gland in such a manner as 
to affect materially the condition of the surrounding parts. Any cause 
producing agitation on the part of the child excites the heart's action, 
the enlarged gland becomes distended and increased in size, presses on 
the vena innominata, and prevents the return of blood from the head. 
The same pressure prevents the venous blood of the thymus itself from 
getting into the innominata, and thus becomes a fresh source of dis- 
tension. The combined result of this is great and dangerous pres- 
sure exercised on the great vessels, preventing the return of blood from 
the head, and thereby suddenly producing cerebral congestion ; on the 
trachea, by which respiration is impeded ; and on the important nerves 
in that situation, especially the sympathetic, the par vagum, and its 
recurrent branches, any interference with which has been found, by the 
experiments of Dr. Alcock, of this city, most powerfully to influence 
respiration, &c.' n 

No doubt these views are stamped with high authority, and with a 
considerable array of learning and research; but there are two important 
facts which meet one at the outset, and which have very great weight, 
so far as the mechanical production of the disease is concerned: — 

1. That in a great majority of cases of spasm of the glottis there is 
no universal hypertrophy of the thymus perceptible during life, or dis- 
covered after death. It is impossible to suppose that such observers as 
Clarke, Cheyne, Hall, Ley, Marsh, Schoepf-Merei, &c, could overlook 
such enlargement ; and yet we have their positive testimony that in 
many cases no morbid changes whatever could be detected, and in 
others the disease existing was not enlargement of the thymus gland ; 
and, 

2. That many cases of enlarged thymus are on record in which the 
symptoms of spasm of the glottis never occurred ; nay, that no affec- 

1 Dublin Med. Journal, vol. ix. p. 437. 



224 SPASM OF THE GLOTTIS. 

tion of the glottis or trachea was observed, although at the same time 
the lungs were seriously affected. 

Dr. Condie remarks : " There has not been adduced a single well- 
established fact to show that an hypertrophied condition of the thymus 
is capable, under any circumstances, of exerting upon the nerves in its 
vicinity such a degree of pressure or irritation as would produce the 
phenomena of the disease under consideration." 1 

I may add that the enlargement of the thymus gland, when it does 
occur, has been regarded as the effect, and not the cause of the spasm 
of the glottis, by Dr. Marshall Hall, and more recently by M. Suiron. 2 

As to the mechanical pressure upon the trachea of the enlarged gland 
producing the disease, it appears more than doubtful, when we consider 
the structure of the trachea, and that the peculiarity of the disease is 
not difficult or impeded respiration, but complete arrest of inspiration; 
expiration, when effected, being quite easy. I doubt whether pressure 
from an enlarged thymus would affect respiration at all; and, if it did, 
I believe it would affect inspiration and expiration equally; that the 
dyspnoea would be less in amount than in the present affection, and not 
so temporary. 

325. With regard to the agency of pressure upon the nerves in caus- 
ing this disease, whether exercised by enlarged thymus or absorbent 
glands of the neck or thorax, according to Dr. Ley, I prefer quoting 
the observations of my friend, Dr. Marshall Hall. "In the first place," 
he remarks, " as far as my memory and judgment serve me, the cases 
adduced to support this view are not cases in point, but in reality cases 
of other diseases. Secondly, supposing pressure upon the par vagum 
to exist, it would induce totally different phenomena from those actually 
observed in this disease ; and it would not explain the series of pheno- 
nema which actually occurs in it ; for, 

" 1. Such pressure would induce simple paralysis. This would, in 
the first place, affect the recurrent nerve and the dilator muscles of the 
larynx; it would not induce a partial but constant closure of that orifice 
— a permanent state of dyspnoea, such as occurred in the experiments of 
Legallois, or such as is observed to be excited in horses affected with the 
'•cornagej or roaring. Secondly, it would induce paralysis of the infe- 
rior portion of the pneumogastric, with congestion in the lung or lungs, 
and the well-known effects upon the stomach of a division of this nerve. 

" 2. The disease in question is obviously a part of a more general 
spasmodic affection, and frequently — indeed, most frequently — comes 
on in the midst of the first sleep, in the most sudden manner, receding 
equally suddenly, to return, perhaps, as before, after various intervals 
of days, weeks, or even months — very unlike paralysis from any cause. 

" 3. It not unfrequently involves, or accompanies, as I have said, 
other affections, indisputably spasmodic, as distortion of the face, stra- 
bismus, contraction of the thumbs to the palms of the hands; of the 
wrists, feet and toes; general convulsions ! sudden dissolution! a series 
of phenomena totally unallied to paralysis. 

"4. Indeed, the larynx is sometimes absolutely closed, an effect which 
paralysis of the recurrent nerve and of its dilator muscles cannot effect. 

1 Diseases of Children, p. 318. 2 Banking's Abstract, vol. i. p. 246. 



SPASM OF THE GLOTTIS. 225 

" 5. Paralysis from pressure of diseased glands would be a far less 
curable, a far less variable disease, a far less suddenly fatal disease, 
than the complete convulsion. 

" Thirdly. Almost all recent cases are at once relieved by attention 
to three or four things, viz: 1, the state of the teeth; 2, of the diet; 
3, of the bowels; and 4, of change of air. They are as obviously pro- 
duced by the agency of errors in one or more of them. 

" Fourthly. In fact, the complete convulsion is a spasmodic disease, 
excited by causes situated in the nervous centres, or eccentrically from 
them. In a case of spina bifida, a croupy and convulsive inspiration 
was induced by gentle pressure on the spinal tumor. In cases from 
teething, the attack has been induced and removed many times by freely 
lancing the gums; and, when it has arisen from crudities, it has been 
relieved by emetics and purgatives, and by change of air, &c. 

"Fifthly. There is a series of facts which prove the connection of 
this disease with the other forms of convulsions in children, and with 
epilepsy in the adult subject. 

" Sixthly. In protracted cases, congestion and effusion within the 
head occur as effects of this disease. 

"Lastly. Innumerable cases of undoubted croup-like convulsions 
have occurred, in which no enlarged glands could be detected in any 
part of the course of the pneumogastric nerve." 1 

826. These reasons appear to me as conclusive against the supposi- 
tion of the disease being caused by the pressure of enlarged thymus or 
bronchial glands upon the nerves, as the former facts were against the 
supposed efforts of mechanical pressure upon the trachea by the hyper- 
trophied thymus : and we have now remaining only those cases in which 
a post-mortem examination records no morbid change or some lesion of 
the brain or its membranes, i. e., as Dr. M. Hall has observed, those 
cases where death has anticipated organic change, and those where 
time has allowed the organs, at first functionally, to be afterwards 
organically disordered. Irritation is excited in the nervous system, 
already perhaps more irritable than usual, 2 from some distant point, 
and is again projected, as it were, to another. I know of no case of 
disease so illustrative of Dr. Marshall Hall's physiological discoveries. 
"It is an excitation," he observes, " of the true spinal or excito-motory 
system. It originates in, 

" 1. a. The trifacial, in teething. 

b. The pneumogastric, in overfed or improperly fed infants. 

c. The spinal nerves in constipation, intestinal disorder, or ca- 

tharsis. These act through the medium of, 

" 2. The spinal marrow, and, 

" o. a. The inferior or recurrent laryngeal, the constrictor of the 
pharynx. 
b. The intercostals and diaphragmatic, the motors of respira- 
tion." 3 



15 



1 Underwood on Diseases of Children, p. 184. 

2 Reid on Infantile Laryngismus, p. 71. 

3 Diseases and Derangements of the Nervous System, p. 71. 



226 SPASM OF THE GLOTTIS. 



327. Causes. — Among the predisposing causes has been mentioned 
the peculiar condition of the larynx in infants, scrofulous constitution, 
hereditary peculiarities, and climate. It certainly is often observed in 
several children of the same family successively, 1 and is undoubtedly 
more prevalent in moist and damp situations. In dry, pure air in the 
country it is almost unknown, whilst it is sufficiently frequent in towns. 

The exciting causes may be stated to include any species of irrita- 
tion capable of exciting the nervous system into irregular but not ex- 
cessive action. Dentition is, perhaps, the most common of such causes; 
next, indigestible food, or overfeeding, constipation, or disorder of the 
bowels, suppressed eruptions. Mr. Coley mentions a curious kind of 
constipation giving rise to it, in which there was an accumulation of 
feces in the colon, with a secretion of viscid mucus, like white paint, 
in the duodenum, and until this was evacuated no relief was obtained. 2 

After what I have just said, I can hardly admit tumors pressing upon 
nerves as exciting causes, except in a different sense to that proposed 
by Dr. Ley. It is quite conceivable that irritation in or from a tumor 
may act in producing the disease in the same way as dentition, though 
not from pressure. 

328. Diagnosis. — The pathognomonic sign of this disease, as Dr. 
Cheyne has well observed, is " a crowing inspiration, with purple com- 
plexion, not folloived by cough." The suddenness of the attack, the 
temporary character of each paroxysm, its facility of reproduction, the 
absence of the normal symptoms of inflammation of the larynx or tra- 
chea, or of much constitutional suffering, are sufficiently characteristic, 
and render the differential diagnosis tolerably easy. 

1. It has been considered as a variety of croup, and has been mis- 
taken in practice for a variety of that disease, or of laryngitis ; but 
in these affections the dyspnoea is permanent, and affects expiration as 
well as inspiration, though not to the same degree, and, notwithstand- 
ing, respiration is steadily performed ; but in spasm of the glottis, it is 
the inspiratory effort which is arrested, and for the time, inspiration is 
absolutely stopped. The rough, metallic sound of croupy breathing is 
quite different from the clear, ringing crowing of the present disease ; 
and moreover, it is evident in expiration, and is accompanied and 
aggravated by a severe cough. In spasm of the glottis there is no 
cough, and in the intervals between the spasms the respiration is 
natural. Lastly, in the present complaint, there is generally little or no 
disturbance of the circulation, and no fever ; but, as the disease in- 
creases, there is a disposition to general convulsions; whilst in croup 
we have high fever, quick pulse, thirst, heat of skin, and no convulsions, 
except at the termination. 

2. The milder forms of the disease are distinguished from convulsions 
by the purely local nature of the spasm, and the absence of constitu- 
tional irritation ; but as the more severe cases may merge into general 
convulsions, the distinction will cease. 

3. From hooping-cough it is easily distinguished, although there is a 
great resemblance between the sound of the hoop and the crowing 

1 Ley on Laryngismus Stridulus, p. 53. 
8 Diseases of children, p. 290. 



SPASM OF THE GLOTTIS. 227 

inspiration, owing to both resulting from the same mechanical condition 
of the larynx, viz : more or less perfect closure, terminating in a forci- 
ble inspiration. But in spasm of the glottis there is very rarely any 
accompanying cough, and the spasm occurs quite independently. There 
is no kink, no expectoration, nor vomiting, nor any catarrhal sounds in 
the lungs. ' 

329. Prognosis. — In all cases the prognosis is grave, and in the 
severe case very serious, because of the implication of the brain, and 
the tendency to terminate in convulsions or in sudden death. One- 
third of Dr. Cheyne's cases died ; Dr. John Clarke says that the 
patient rarely recovers ; Dr. Gooch states, that it proves fatal to one 
third of those attacked. Of Sir H. Marsh's cases, five recovered and two 
died. In Dr. Hirsch's cases, three out of five died. And it appears to 
be more fatal with males than females. Gervino and Gardien think it 
almost always fatal if remedies be not employed in the early stage ; and 
this seems to be the general opinion ; but, on the other hand, if the 
complaint be recognized, and the treatment early and prompt, the symp- 
toms will, in many cases, yield to the remedies employed. 

The change which indicates a favorable termination is a diminution in 
the frequency and duration of the paroxysms, and freedom from any 
complications. The unfavorable symptoms are an increase of the spasms, 
spasmodic affections of the limbs, or general convulsions. 

330. Treatment. — Fortunately, however different opinions may be 
as to the nature of the disease, all are unanimous as to its treatment. 
The first thing to be attended to is to remove all exciting causes, and 
according to them will be the treatment. If the child be teething, 
" the augmented arterial action within the gums and alveolar processes 
must be subdued by deep, diffused, and repeated scarification of the 
gums, conducted with every precaution to avoid excitement of a mental 
kind." 1 

If we suspect overfeeding, or that indigestible food has been taken, 
the stomach must be emptied by an emetic, or by tickling the fauces 
with a feather; and the effect of accumulation, or disorder of the bowels, 
may be removed by one or two brisk purgatives of calomel and jalap, 
or rhubarb, or by large enemata of warm water. If the air of the room 
in which the child has been confined be close and impure, it must be 
removed to a larger apartment, or fresh pure air admitted. 

331. During the paroxysm, the child should be placed in an upright 
position, with the head leaning a little forward, and exposed to a current 
of pure fresh air, whilst cold water is sprinkled on the face. If this fail, 
the child may be placed in a warm bath, and cold water sprinkled in its 
face; in short, whatever is calculated to induce a more forcible effort at 
inspiration. Dr. Condie mentions that the application of ammonia to 
the nostrils is useful, or tickling the fauces with a feather, so as to induce 
vomiting. 2 

If these means fail, an attempt must be made at artificial respiration. 
In extreme cases, it has been a question whether tracheotomy ought 

1 Lancet, July 12, 1847. 

2 Diseases of Children, p. 358. 



228 SPASM OF THE GLOTTIS. 

not to be performed; and certainly, in prospect of instant death, it may 
be right to try some extreme measures ; but the advantage to be derived 
from this operation is by no means certain, and as yet we want facts to 
warrant our recommending it. 

Mr. W. J. Cox has used chloroform during a paroxysm with great 
success. " In a few seconds, the muscles will be relaxed, the spasms 
will be over, and the little patient will breathe freely." 1 A few drops 
of the fluid should be sprinkled on a handkerchief, or poured into the 
hand and held before the mouth. 

Generally speaking, the paroxysm terminates too quickly to allow of 
much interference. 

332. During the intervals, our object should be to diminish the fre- 
quency of the spasm, and to improve the general health. 

In very few cases is bleeding either necessary or useful ; in many, it 
would do mischief by weakening the vital powers. When the child is 
robust, florid, and plethoric, a few leeches may, perhaps, be beneficial; 
but when there is any threatening of general convulsions, or any other 
evidence that the brain is more than usually involved, then prompt 
bloodletting will form a necessary and important part of the treatment. 

Purgatives are universally recommended, not powerful doses, but 
moderate ones, repeated three or four times a week, so as to clear out 
the bowels and act as a derivative. Dr. M. Hall strongly recommends 
the antacid aperients. 

Antispasmodics have been found useful. Millar gave assafoetida in 
large doses ; the proper dose, however, for a child of two years is from 
one to two grains, and four to six grains for a child from five to ten 
years. Dr. John Clarke used ether and ammonia; Dr. Underwood 
assafoetida, oleum succini, tinct. fuliginis, of the old pharmacopoeia, 
musk, cicuta, &c. Musk may be given in doses of two to five grains, 
every six or eight hours, to a child of three years old and upwards. 
Sir H. Marsh tried the tincture fuliginis with benefit, and, in one case, 
an infusion of tobacco leaves (gr. v to ovj) as an enema. Dr. Stewart 
speaks highly of a poultice sprinkled over with Scotch snuff. Drs. Ley 
and Davis gave henbane with relief; or, if the child be restless, a little 
Dover's powder may tranquillize it ; and Dr. Chas. D. Meigs recom- 
mends the application of ice to the epigastrium. 

In cases where dysuria w T as present, Dr. Davis derived great benefit 
from a combination of hyoscyamus, spirits of nitrous ether, and almond 
milk. When the fauces are swollen, they may be washed over with a 
solution of the nitrate of silver, with a cameUs-hair pencil, or of a 
mixture of dilute sulphuric acid and syrup. 

333. It will be advisable in most cases to apply some form of counter- 
irritation, either some irritating liniment, or a blister, or, what I have 
found far better, a small seton in the arm. In one case under my care, 
the moment the seton discharged fairly, the spasms ceased, and when- 
ever it w T as left out they returned. 

334. With almost all children who have the disease for some time, 
but especially with those of a delicate constitution, tonics will be found 

1 Lancet, Sept. 1, 1849. 



PERTUSSIS. 229 

beneficial. Sulphate of quinine, infusion of cascarilla, or of hops, as 
advised by Dr. Ley, or some of the preparations of iron, may be given 
in doses suitable to the age of the child. Dr. Davis recommends the 
vinum ferri, combined with the carbonate of ammonia and hyoscyamus, 
if the child be languid and irritable ; Mr. Cox the citrate of iron, 
with small doses of hydrocyanic acid to allay irritation (a quarter of a 
minim three times a day to a child three years old). 

Dr. Schoepf-Merei states that no remedy is equal to the cod-liver oil, 
in doses of two to four teaspoonfuls a day to a child of three or four 
months old, increasing according to the age. 

Attention to the diet of the child is of great importance. We may 
succeed in removing the disease, and improper food will instantly repro- 
duce it. The food should all be of a bland nutritious character, and 
moderate in quantity. If there be any danger of over-indulgence, or 
of imprudence, it will be better to adopt Dr. M. Hall's plan, and fix 
upon one kind of food to the exclusion of all other. Dr. Montgomery 
very wisely cautions us against laying infants on their back when feed- 
ing, if they are liable to this disease, and against hasty feeding. 

In the case of infants at the breast, it will be prudent in many cases 
to change the nurse. 

Lastly, I have already alluded to the necessity of a pure atmosphere 
within the room in which the child lives. I must add that the tempera- 
ture ought to be carefully regulated, so that it shall neither be too hot 
nor too cold; and also that the clothing of the child should be sufficient, 
according to the season, without being oppressive. But very special 
benefit, as Sir H. Marsh and Mr. Roberton have shown, is derived from 
change of air. After we have removed all the causes within our reach, 
prescribed antispasmodics and tonics, we shall often find more imme- 
diate benefit from a removal to the pure mild air of the country than 
from all our medical treatment in town. This should be done as early 
in the disease as possible, in order to check its progress. 

Should the disease increase in spite of all our efforts, and issue in 
general convulsions, then the treatment must be adopted which I have 
recommended for that disease. 



CHAPTER III. 

PERTUSSIS — HOOPING-COUGH. 

335. I have placed hooping-cough next in order to spasm of the 
glottis because of the similarity between them, the former constituting 
a transition from purely spasmodic to inflammatory affections, being a 
mixture of both. 

Dr. Cullen has given a brief but accurate description of this disease : 
" Morbus contagiosus, tussis convulsiva, strangulans, cum inspiratione 
sonora, iterata, ssepe vomitus." Dr. Copland's definition is an expan- 



230 PERTUSSIS. 

sion of this, with more details. He says that it is " a convulsive and 
suffocative cough, accompanied with a reiterated hoop, or consisting of 
many successive short expirations, followed by one deep and loud inspi- 
ration, and these alternating for several times ; occurring in paroxysms, 
ending with the expectoration of tough phlegm, and frequently with 
vomiting ; infectious, and often epidemic, appearing but once during 
life." 

It has obtained various popular and learned names: chin-cough, kink- 
cough, and hooping-cough, in England ; kinkhoast, in Scotland ; coque- 
luche, in France; and, in Germany, keichhusten, stickhusten, eselshus- 
ten, &c. By Willis, it was called tussis convulsiva ; by Hoffman, tussis 
ferina ; and by Sydenham, pertussis. 

336. It is very doubtful whether it was known to the ancients. No 
accurate description is to be found in the Greek or Arabian -writers; 
and the disease is so peculiar that they could hardly have omitted to 
notice it had it been familiar to them. It has, therefore, been supposed 
by Rosen that it came from the East Indies and Africa into Europe. 

The earliest record of it we find is by Mezeray, as it occurred in 
France in 1414 ; but Dr. Copland considers that there is nothing cha- 
racteristic about his description, or the subsequent ones of De Thou 
and Pasquier, but the name " coqueluche." 

The first accurate account is by Willis, 1 who was followed by Millar, 2 
Sydenham, 3 Alberti, 4 Brendel, 5 Butler, 6 Danz, 7 Paldam, 8 Perrada, 9 
Watt, 10 Marcus, 11 &c. ; and more recently by Guibert, 12 Desruelles, 13 
Blaud de Beaucaire, 14 Blache, 15 Roe, 16 C. Johnson, 17 Duges, 18 Copland, 19 
&c. ; besides excellent notices in the systematic works of Dewees, 
Eberle, Stewart, Condie, Maunsell and Evanson, Coley, Barrier, Bar- 
thez and Rilliet, Bouchut, &c. 

337. Hooping-cough has this peculiarity in common with some erup- 
tive diseases, that it occurs once, and in general but once in a lifetime; 
and consequently almost always in infancy or childhood, i. e. the first 
time the child is exposed to the peculiar exciting cause, whether that be 
epidemic miasma, or contagion. Thus we find the most common age is 
between two and ten years. 

Dr. Watt has given the following table of the ages at which death 
from hooping-cough occurred in Glasgow during thirty years: — 

1 Opera Omnia, Amst. 1682, vol. ii. p. 169. De Morbus Convulsiva Puerorum, &c. 

2 Obs. on Asthma and Hooping-cough, 1769. 

3 Opera Universa, 1726, p. 311. 4 De Tussi Infant. Epidemica, 1728. 
5 Prog, de Tussi Convuls., 1747. 6 A Treatise on Kink-Cough, 1773. 

7 Versuch einer Allgem. Gesch. des Keichhustens, 1791. 

8 Der Stickhusten, 1805. 9 Memoria, &c. Verona, 1815. 

10 Treatise on the History and Treatment of Chin-Cough, 1813. 

11 De Keichhusten, 1816. 

12 Recherches sur la Croup, et la Coqueluche, 1824. 

13 Traite de la Coqueluche, 1824. 14 Revue Med., 1831. 
- 15 Archives Gen., vol. iii. 1833. 

16 Treatise on the Nature and Treatment of Hooping-cough, 1838. 

17 Cyclopaedia of Practical Med., vol. ii. p. 428. 

18 Diet, de Med. et de Chir. Pratiques, vol. v. p. 487. 
)9 Diet, of Medicine, part. v. p. 236. 







PERTUSSIS. 




Under 6 months 




in 135 cases 


Abcrv 


e6 " 


and under 1 year, 


" 357 " 


" 


1 year 


" 2 years, 


" 596 " 


" 


2 years 


3 " 


" 333 " 


" 


3 " 


4 " 


"186 " 


«' 


4 " 


5 " 


" 109 « 


« 


5 " 


6 " 


" 37 " 


" 


6 '• 


7 " 


" 34 " 


<< 


7 " 


8 " 


" 12 " 


" 


8 " 


9 " 


" 10 •' 


" 


9 " 


10 " 


" 5 " 


" 


10 years, 




. 3 » 



231 



1817 

The author states, that this may be considered about half of the 
deaths in Glasgow from this cause. 

Out of 130 cases collected by M. Blache, 106 were from one year 
old to seven, and twenty-four from seven to fourteen years. Of twenty- 
nine cases observed by Rilliet and Barthez, three were from one to two 
years old; five, three years; seven, four years; six, five years; two, six 
years; three, seven years; one, eight years ; one, nine years; and one 
twelve years old. 1 Dr. Hood mentions having seen a child of a fort- 
night old, 2 and Dr. C. Johnson one of three weeks old, attacked by the 
disease. 

On the other hand, it has undoubtedly occurred more than once in 
the same individual, some say even three times ; and cases are on 
record of persons who had escaped until a very advanced period of life. 
Eberle mentions two cases occurring after fifty years ; and Heberden 
one in a woman of seventy, and another in a man of eighty. 

Boys and girls are of course equally exposed to the attack, and yet, 
according to the researches of Blache and Constant, a greater number 
of boys arrive at maturity without having had the disease. Blache 
proved the proportion of such cases to be seven boys to six girls, and 
Constant, three boys to two girls. 3 

338. Symptoms. — The disease has been divided generally into two 
or three stages. Desruelles and Lombard have a period of invasion, a 
period of increase, and a period of decline ; Blache and Williams divide 
it into the inflammatory, congestive, and nervous stage ; others into 
the catarrhal and spasmodic stages, which is at any rate the simplest 
and most natural division. The period of decline is simply the termina- 
tion of the second or spasmodic stage. 

The first stage commences with the usual symptoms of catarrh. The 
child appears to have caught cold ; it is languid, restless, feverish, and 
irritable without cause. There is loss of appetite, sneezing, coughing, 
and an extra secretion of mucus from the membrane lining the nose 
and bronchial tubes after the first day or two. 

This is by far the most general mode of invasion, a well-marked but 
not very severe catarrh ; but occasionally we find the patient suffering 
much more, the fever intense, great thirst, the pulse quick, the oppres- 
sion and general distress considerable, the cough very frequent and 

1 Mai. des Enfans, vol. v. ii. p. 230. 2 On the Fatal Diseases of Children, p. 103. 
3 Barrier, Mai. de l'Enfance, vol. i. p. 370. 



282 PERTUSSIS. 

painful, dry at first, but with profuse expectoration afterwards. The 
bowels, according to Dr. Watt, are generally constipated, and require 
large doses of medicine for their relief; but this, I think, is not gene- 
rally the case. 

In some few cases there is no evidence of the existence of this first 
stage ; the child is at once seized with the characteristic cough, without 
any irritation of the mucous membrane. M. Blache mentions that the 
child of his colleague, Dr. Tavernier, set. two years, was brought home 
from the country in perfect health, and without the slightest cold. The 
day after she was playing with two children who had hooping-cough. 
In the evening of the second day she had an attack of shrill, spasmodic 
cough, which proved to be hooping-cough, and continued for two months 
without any complication. 1 

On the other hand, Dr. Watt observes that the disease, throughout 
its course, may present this character only. 2 "I have had instances of 
a disease," says Dr. Cullen, "which, though evidently arising from the 
chin-cough contagion, never put on any other form than that of a com- 
mon catarrh." 3 And Dr. Burns observes that, "in young children, 
even death may take place, although the disease never fully forms ;" 
and his observation is confirmed by M. Duges. I think, however, that 
in such cases there must ever remain a doubt as to the true nature of 
the disease. 

389. These catarrhal symptoms continue for twelve or fourteen days, 
but gradually subside, the fever and coryza diminish, the pulse becomes 
quiet, and the appetite returns. 

The cough, indeed, persists, or even appears aggravated, but it exhibits 
a change of character. Instead of being a simple cough, with few suc- 
cessions, we find it prolonged by a succession of expiratory efforts, and 
at its termination we occasionally hear a forcible inspiration, accompa- 
nied by a loud ringing sound. The prolonged paroxysm of coughing, 
or kink, and the hoop, mark the commencement of the second stage, as 
the subsidence of the catarrh does the termination of the first. 

The cough is very peculiar ; when fully established we find "a number 
of expirations made with such violence, and repeated in such quick suc- 
cession, that the patient seems to be almost in danger of suffocation. 
The face and neck are swollen and livid, the eyes protruded and full of 
tears ; at length one or two inspirations are made with similar violence, 
and by them the peculiar hooping sound is produced ; a little rest pro- 
bably follows, and is succeeded by another fit of coughing, and another 
hoop ; until, after a succession of these actions, the paroxysm is ter- 
minated by vomiting, or a discharge of mucus from the lungs, or perhaps 
by both." 4 The child is perfectly conscious of the approach of the cough; 
he feels a sensation of rattling in the chest, and tickling in the larynx, 
which he endeavors to suppress, and the struggle continues until his 
resistance is overpowered by the irritation. 

The paroxysms, or a rapid succession of them, may last from one to 
fifteen minutes, and in proportion to the violence and length will be the 

1 Diet. Ge"n. des Sciences M6d., art. Coqueluche, p. 24. 

2 On the Chin-cough, p. 37. 3 First Lines of the Practice of Physic, sect. 1400. 
4 Dr. C. Johnson, Cyclop, of Pract. Med., vol. ii. p. -128. 



PERTUSSIS. 233 

breathlessness and fright of tho child, and its efforts to inspire. If lying 
down, it will suddenly jump up, and seize hold of whatever is nearest, so 
as to make a fulcrum, as it were, for the whole muscular force of the 
body, which is employed in overcoming the spasm. 

The paroxysm most generally terminates in vomiting, but if it be very 
violent, some small vessels may be ruptured, and blood escape from the 
nose or mouth, or it maybe effused beneath the conjunctiva, or be mixed 
with the expectoration. 

After the fit of coughing is over, the child appears exhausted, and 
requires a short rest to recover itself; but then, and during the interval 
until the next cough, it appears tolerably easy and cheerful, occupied 
with its usual plays, and not averse to food. If the attack be severe, 
it will be pale, thin, and languid. 

840. The length of the intervals, and the frequency of the parox} r sms 
vary a great deal. At first, and for some time, they are very frequent 
when the disease is severe. I have known them occur every half-hour 
during the day and night ; but in other cases they return every five or 
ten minutes during the day, and less frequently at night, though the 
paroxysms are rather more severe. 1 

The principal cause of their return is the accumulation of mucus if 
the secretion is profuse. Frequent efforts will be made to get rid of it, 
and if it be easily expelled, in sufficient quantity, the fit will be light, 
and the interval easy. If it be scanty and tenacious, the paroxysm 
will be violent, the efforts great, and the cough renewed almost imme- 
diately, or it will occur in double paroxysms. 

A full meal, a fit of anger, crying, fright, or laughter, will generally 
bring on the cough ; nay, even the force of sympathy will have a similar 
effect, for it is mentioned that, in the case of two children who had 
hooping-cough, when one had a fit of coughing, the other immediately 
began also. 

In some rare cases, towards the decline of the disease, the paroxysms 
have assumed a periodic character, returning at a given hour. A case 
of this kind is mentioned by Dr. Good; 2 it occurred daily at a certain 
hour, continued obstinately for several months, and returned at the same 
season for two years. 

341. The expectoration which, during the first stage, was a frothy 
mucus, assumes, in the second stage, a very tenacious character ; it may 
be clear and transparent, or yellow, and even puriform, but still thick, 
tenacious, and ropy, so that it may be drawn out of the infant's mouth 
with the fingers. 

If we make a stethoscopic examination of the chest during the first 
stage, we shall find the mucous or sibilant rhonchi, characteristic of the 
catarrh; and the respiratory murmur somewhat weaker than usual. 

The chest is clear and sonorous on percussion. 

During the second stage, when the hooping-cough is fully developed, 
Laennec observes that, "during an interval, we find but the ordinary 
symptoms of catarrh, i. e. the respiratory murmur more feeble than usual, 
or altogether absent in some parts, otherwise resonant; puerile in others, 

1 Marley on Diseases of Children, p. 157. 2 Study of Medicine, vol. ii. p. 393. 



234 PERTUSSIS. 

with mucous or sibilant rales. During the paroxysms we perceive only 
the vibration of the trunk, from the shock of the cough, and we only 
hear a slight rhonchus or the respiratory murmur in the short intervals 
between the successions. The hooping inspiration, so characteristic, 
seems limited to the larynx and trachea. Neither pulmonary nor 
bronchial respiration is heard, even in those parts where puerile respi- 
ration had been audible a few minutes before." 1 

Similar testimony is borne by Dr. Williams ; he says : "On applying 
the ear to the chest during a fit of hooping-cough, one is surprised, with 
such violent external motions, to hear so little sound of respiration 
within the chest ; and, during the sonorous back-draught, there is 
scarcely any sound of air entering the lungs. This is to be ascribed to 
the continued contraction of the glottis and large bronchial tubes, pre- 
venting the air from entering the pulmonary texture with sufficient force 
to produce the ordinary respiratory murmur." 2 

All writers agree pretty much with this description when the disease 
is uncomplicated ; and, so far as the positive part is concerned, I have 
no doubt it is true, but I think more can be heard during the intervals 
in well-marked cases than is here mentioned. I have examined a great 
many children at intervals, from one paroxysm to another, and I have 
in a great many cases found that, after the chest had been cleared by 
the last cough and vomiting, the respiratory murmur or inspiration was 
louder, and more rough than usual, nay, in some cases, that it had a 
rather loud, brazen sound, something resembling a loud sonorous rale, as 
if the air was passing through tubes much narrower than usual. It is 
perceptible, also, in expiration, though more feeble. 

This sound may continue until the mucus begins again to accumulate, 
and then it will be exchanged for the large, mucous, bubbling sound, 
which increases until the next cough, and is almost universal. 

In milder cases the rough dry sound is more feeble, though gene- 
rally audible, and I think this loud, rough murmur of inspiration and 
expiration quite peculiar to pertussis. The chest is clear on percussion 
throughout this stage in simple cases. 

The explanation given of the cough and the hoop by Dr. Roe is, 
I think, satisfactory: "Any one who will make the experiment will 
perceive that by the exercise of the voluntary muscles of respiration, 
he cannot either continue coughing loudly for so long a time, or empty 
the lungs so completely of air, as a person does in a paroxysm of hoop- 
ing cough ; it must, therefore, be inferred that the involuntary muscles, 
namely, those pointed out by Reisseissen, as connecting the extremities 
of the cartilaginous rings of the trachea and bronchise, powerfully 
assist in accomplishing both these objects. They seem, by acting spas- 
modically, to expel the air from the lungs, and to excite, by sympathy 
the voluntary muscles of inspiration ; the combined action of both sets 
of muscles appears to produce this peculiar cough." I think it ex- 
tremely probable that the spasmodic action involves the smaller bron- 
chial tubes as well as the larger. "The hoop takes place in the larynx 

1 Del' Auscultation Mediate, vol. i. p. 188, 2d ed. 

2 Pathology aud Diagnosis of Diseases of the Chest, p. 89. 



PERTUSSIS. 235 

and trachea, and appears to be caused by a rush of air through a con- 
tracted passage, for no sudden or violent inspiration could produce this 
sound in the natural healthy state of the air-tubes. The lungs are so 
completely emptied of air, by long-continued expirations, that a most 
distressing sense of suffocation is produced, to relieve which, a full 
inspiration is instinctively made, and at the same moment the rima glot- 
tidis is contracted, and the air passing quickly through a very narrow 
opening, causes the hoop." 1 

The action of the heart is excessively quick and strong, and it is a 
little time before it subsides to the natural standard during an interval. 

342. The second or spasmodic stage persists a considerable time, 
generally six weeks or two months, but often three, four, or six months: 
if we make a third stage, one month may be allotted to the spasmodic 
stage, and the remainder to the stage of decline. 

The effects upon the child will be pretty much in proportion to the 
violence and duration of the disease, and the susceptibility and delicacy 
of the constitution. They are seldom of serious importance, however, 
if the pertussis be uncomplicated. The appetite is generally diminished, 
and the digestion disturbed by the frequent vomiting ; nutrition is not 
very effective, and the child loses flesh. The sleep is interrupted, the 
circulation deranged by the excitement of the cough, the surface is 
moist, with profuse sweating sometimes ; the flesh is generally flabby, 
and the skin is of a darker hue, especially underneath the eyes ; the 
spirits are unequal, often depressed. 

As the disease declines, the paroxysms become less frequent, though, 
perhaps, equal in violence. They now occur but four or five times 
during the day, and rarely at night ; ultimately, towards evening only, 
and under special excitement, and then are reproduced at distant in- 
tervals only, and with much less violence, until they cease altogether. 
Meanwhile, if not too much exhausted, the constitution begins to re- 
cover its healthy condition ; tranquil sleep restores the nervous system ; 
the absence of vomiting allows the food to be digested, and the child 
recovers flesh and spirits ; the circulation returns to its normal condi- 
tion, and the surface assumes its natural aspect. 

343. Thus we may find that in simple pertussis the first stage is cha- 
racterized by the symptoms of common catarrh, which, however, are 
occasionally absent, and the second stage by the peculiar prolongation 
of the cough in inspiration, i. e. the kink and the forcible inspiration or 
hoop. In some very rare cases the kink is but little remarked, but it 
is always present in a greater or less degree, and is, so far, more cha- 
racteristic than the hoop, which is not unfrequently absent. The 
presence of either will prove the nature of the disease, but the absence 
of both would, of course, deprive us of the power of diagnosis. 

The entire duration of the disease is from two to four months. Ac- 
cording to popular belief it is six weeks coming to its height, and six 
weeks going off; but it maybe almost indefinitely prolonged, as, for 
some time afterwards, the hoop returns when the child catches cold. 
Marley mentions a case in which the symptoms did not disappear for 

1 On Hooping-cough, p. 44. 



236 PERTUSSIS. 

two years : x and Dewecs and others mention its continuance for twelve 
months. 

According to Barrier, 2 the child may die in simple hooping-cough, 
from the intensity of the kinks : it may, in short, be suffocated. The 
disease may also prove fatal from exhaustion, and the child die, utterly 
worn out, according to Hamilton, 3 Barrier, and others; or, what is more 
common, it may lay the foundation of other diseases, such as dilatation 
of the bronchial tubes, phthisis, epilepsy, struma, ophthalmia, &c. "In 
scrofulous habits," says Dr. Watt, "the disease is not so apt to prove 
suddenly fatal ; but if it be severe and protracted, it generally ends in 
some affection of the glandular system, laying the foundation for tabes 
mesenterica, rickets, or pulmonary consumption." 4 

344. Complications. — So far I have spoken only of simple hooping- 
cough, but we find that a very large proportion of the cases during some 
part, at least, of their course, are complicated with other secondary 
affections, and a careful inquiry will establish the fact, that it is to these' 
complications that almost all the mortality is owing. Simple hooping- 
cough is rarely fatal, and yet the mortality in hooping-cough is very 
great, arising from the liability of other organs to take on morbid ac- 
tion, and from the circumstance that in three out of the four most fre- 
quent complications the hooping-cough causes and reproduces them. I 
shall notice complication with, 

1. Bronchitis or pneumonia. 

2. Infantile remittent. 

3. Congestion of the brain, convulsions, or hydrocephalus. 

4. Sanguineous apoplexy. 

Other minor or more rare complications are mentioned occasionally 
by authors, but I shall content myself by noticing, briefly, the foregoing. 

345. I. Pertussis complicated with Bronchitis and Pneumonia. — ■ 
This will be found in these countries the most frequent, and one of the 
most fatal of all the secondary diseases. Of Barrier's cases, seven out 
of ten died of lobular pneumonia. Of twenty-seven fatal cases under 
Dr. West's care, thirteen died from bronchitis or pneumonia. 5 Dr. 
Copland attributes the frequency of this complication during the winter 
to the variable climate of these countries, and the prevalence of easterly 
winds. 

The attack, as we have seen, commences with some degree of bron- 
chitis ; this maybe very intense, and it may continue on during the 
second stage instead of subsiding, or it may occur at any subsequent 
period, either from the stress thrown upon the lungs, from a strong pre- 
disposition, or from cold. The same may be said of pneumonia, except 
that the latter is more common during the second stage than the first, 
and in children of a full habit of body. 

The age has little to do with these complications. They are met with 
in children of all ages, and very often creep on very insidiously, so as 
to deceive the physician as well as the nurse, unless he adopt the proper 
precaution of auscultating the chest very frequently. I would strongly 

1 Diseases of Children, p. 159. z Mai. cle l'Enfance, vol. i. p. 378. 

3 Diseases of Infants, p. 169. 4 On the Chin-Cough, p. 75. 

6 Medical Gazette, Feb. 25, 1848, p. 311. 



PERTUSSIS. 237 

recommend that this should be done at each visit, as a matter of duty, 
in all cases of hooping-cough, and minutely and thoroughly whenever 
we suspect the existence of more than the simple affection. 

The presence of bronchitis or pneumonia during the first stage may 
be suspected by the greater amount of constitutional disturbance, the 
quick pulse, high fever, loss of appetite, dyspnoea, and incessant cough, 
with a diminution or cessation of the hoop, and we may certainly as- 
certain the fact by percussion and auscultation. 

346. During the second stage, after the subsidence of the catarrhal 
fever, the occurrence of bronchitis or pneumonia will generally be 
marked by the return of the fever, loss of appetite, the increase of the 
cough, and the addition of difficult or hurried respiration during the 
intervals, as well as by constitutional disturbance in proportion to the 
intensity of the disease. We need, however, to be very watchful, for 
in some cases the inroad of the disease is very gradual, and marked by 
few symptoms, until the little patient is beyond aid. 

It is not necessary that I should here detail minutely the symptoms 
and course of either complication ; they will be found in the proper 
place ; it will be sufficient to notice, that the child will generally be 
found to be very feverish, restless, sleeping uneasily, with a quicker 
pulse, greater thirst, hotter skin than usual, and a red flush on one or 
both cheeks. The respiration is considerably affected, quick, hurried, 
and difficult, the chest heaves, the alse nasi expand, and the muscles of 
the chest and abdomen are in vigorous action, even during the intervals 
of coughing. We may sometimes count thirty, fifty, eighty, or a hun- 
dred respirations per minute, and the pulse will be, in proportion, fre- 
quent, and in general hard. 

" The cough is generally aggravated in frequency, and more distress- 
ing, but in severe cases it may altogether lose the spasmodic character, 
and exhibit that of the cough in bronchitis or pneumonia. If the cough 
had already declined, it may return, as during the early part of this 
stage. 

The expectoration is" more difficult, the sputa being less profuse and 
tenacious, and of a puriform appearance. 

As the disease advances, the cough may diminish, but the wheezing 
and dyspnoea increase, the fever continues, the respiration is more fre- 
quent, hurried, and labored, the pulse very rapid, small, and feeble, the 
cheeks and lips purple, the surface cold and clammy, and death soon 
closes the scene. 

347. If the child be attacked by bronchitis, we shall find the chest 
generally clear on percussion; in some parts there may be a degree of 
dulness, but it is never either extensive or absolute. 

By the stethoscope, sonorous, sibilant, and mucous rales will be heard 
over a portion or the whole of one or both lungs. 1 think I have more 
frequently seen both lungs affected than one alone, and it will be ob- 
served that these rhonchi are as audible immediately after a fit of cough- 
ing, and during the interval, as just before the cough comes on, therein 
differing widely from simple hooping-cough. 

The respiratory murmur will be feebler than usual, and more or less 
mask*ed by the bronchitic rales. 



238 PERTUSSIS. 

In cases of secondary pneumonia, the chest is dull on percussion over 
the diseased portion of the lung, but resonant in other parts. 

The stethoscope will detect a crepitating rale in the early period of 
inflammation, with puerile respiration in the surrounding lung, or, if 
the entire lung be involved, the respiration will be puerile in the other. 

At a more advanced stage, we may find a portion of the lung solidi- 
fied, absolutely dull, without respiration or rhonchus, but in which 
bronchophony will be audible. 

If the child live until suppuration be established, which is very sel- 
dom the case, there may be heard a large mucous bubble, or a large 
crepitus, with, perhaps, cavernous respiration, and the dulness, on per- 
cussion, may diminish. 

So, in the progress of recovery, the lung which was solified, and im- 
permeable to air, will now yield at first a mucous or crepitating rale, 
and then gradually more and more respiratory murmur, with increasing 
resonance on percussion ; and along with this local amelioration, we 
shall have a diminution of the dyspnoea and rapid breathing, a return 
of the natural cough, a quieter pulse, calmer sleep, and restoration of 
appetite. 

348. II. Pertussis complicated tvith Infantile Remittent. — I have 
already mentioned that the condition of the stomach and bowels is 
variable in hooping-cough ; they may be pretty regular, or they may be 
much disordered ; and in our anxiety about the principal affection, they 
are liable to be neglected. During the first stage, the effect upon the 
concurrent disease, and upon the infant may be comparatively slight, 
but in the second stage, when the constitution is somewhat shaken, it 
may prove more serious, and require great attention and prompt treat- 
ment to prevent it running on into infantile remittent and its con- 
sequences. This disordered condition of the bowels will be marked by 
a foul, loaded tongue, loss of appetite, tympanitic abdomen, and un- 
healthy discharges. These may continue for some time, and then, if 
not relieved, symptoms of infantile remittent will arise. " After the 
symptoms just enumerated have continued for a longer or shorter time, 
the fever makes its appearance, sometimes commencing with a rigor ; 
more frequently, however, it comes on so gradually that we do not 
know precisely when to date its commencement. The paroxysms of 
coughing become more frequent, and the breathing is quickened and 
oppressed ; but still it may be, with a little care, distinguished from the 
attack of bronchial inflammation. The stethoscope affords us useful, 
though negative evidence. The usual symptoms of bronchial inflamma- 
tion are absent. The frequency and force of the respiration are found 
increased, but this increase is not accompanied by any rale indicative 
of bronchial inflammation ; while the daily remissions, the loaded 
tongue, the nature of the alvine discharges, the aspect of the child, 
constantly picking its nose and lips, all serve to determine the true 
character of the disease." 1 

There is a marked difference between the inspiration in this and the 
last complication; in the former it was quick, hurried, and difficult; 

1 Dr. C. Johnson, Cyclop, of Pract. Med., vol. ii. p. 430. 



PERTUSSIS. 239 

in the present it is quick, hurried, and somewhat unequal, but not diffi- 
cult. 

The fever, also, unlike that which accompanies hydrocephalus, has 
distinct remissions in the morning, and increases towards evening ; 
■whereas, in the majority of cases of meningitis, it is nearly equal, and 
certainly without distinct remissions. It must not be forgotten, how- 
ever, that infantile remittent may terminate in hydrocephalus, if not 
relieved. 

This complication is neither so frequent nor so formidable as the 
last, but quite sufficient to render the disease very intractable, and often 
fatal. 

349. in. Pertussis complicated with Congestion of the Brain, Con- 
vulsions, or Hydrocephalus. — We might anticipate the occurrence of 
these complications, even before experience had proved the fact. If 
we watch a child during a paroxysm of hooping-cough, and notice the 
great congestion of the vessels, of the head, face, and neck during the 
fit, and observe how often this is repeated during the day for weeks 
together, and remember the delicate condition of the brain in young 
children, and especially in infants, our wonder will be, not that these 
cerebral affections occur at all, but that they are not more frequent. 

These attacks may occur in children of any age, but I think are 
more common in young infants, or about the period of the first denti- 
tion, and they are highly dangerous, if not generally fatal. Dr. West 
mentions that fourteen of his twenty-seven fatal cases died from conges- 
tion, convulsions, or hydrocephalus ; and all who have had much ex- 
perience will admit the rarity of cure, and the rapidity with which they 
run on to a fatal termination. 

These complications may accompany the disease at its commence- 
ment, or may arise at any period of its course. Dr. West remarks 
very truly, " The nervous system sometimes suffers so severely from the 
very first, that death takes place almost before the disease has had time 
to assume its usual character. At other times, hooping-cough comes on 
naturally ; its two elements, the bronchitic and the nervous, if I may 
be allowed the expression, increase daily in intensity, till, all at once, 
the symptoms of the former recede, and are almost lost in those of the 
latter, which, in a day or two, bring on the fatal termination of the 
case. Or, lastly, no symptoms referable to the nervous system call for 
our solicitude until after the hooping-cough has continued many weeks; 
but then the long continuance of the disease seems to excite mischief 
in the brain, and death overtakes the patient when we had already 
begun to hope that nothing more than time was needed to perfect his 
cure." 1 

350. We may fear the occurrence of one of these complications when 
we find the cough increase in severity, without either of the former 
complications ; the face become livid, and remain so longer than usual ; 
the existence of the carpo-pedal spasm, the previous occurrence of nerv- 
ous affections, any hereditary taint, or the occurrence of convulsions or 
hydrocephalus in other members of the family. 

1 Lectures in Medical Gazette, Feb. 25, 1848, p. 312. 



240 PERTUSSIS. 

Probably the earliest symptoms will be an unusual sleepiness and 
heaviness after the fits of coughing, with an uncertain look of the eyes, 
or stare, or spasmodic twitchings of the face or extremities, carpo-pedal 
spasm, sometimes an attack resembling spasm of the glottis ; and any 
of these may be followed by an attack of convulsions and coma, or coma 
without marked convulsion. 

Or perhaps the first evidence of the brain being seriously affected may 
be a fit of convulsions, fatal in some cases, but from which the patient 
generally recovers, to be again attacked when the congestion from 
coughing reaches a certain point. The convulsion, when repeated, does 
not return with every fit of coughing, but generally as the result of a 
very severe paroxysm. This constitutes our great difficulty in the treat- 
ment; we may relieve the head temporarily, but just as we fancy our- 
selves successful, a cough of unusual violence destroys all the effects of 
our previous exertions. 

Meningitis, or hydrocephalus, may set in in the same manner, or it 
may creep on more insidiously, until at length it be manifested by the 
usual symptoms, as heretofore described. 

Dr. West has given a striking example of the insidious manner in 
which tubercular meningitis may come on during hooping-cough, and 
prove fatal, without affording us an opportunity of suitable treatment. 

351. These diseases will generally run the course I described when 
treating of them, modified partly by the presence of the cough, as a 
permanent exciting cause, partly by the influence they in turn exercise 
upon the cough, and partly by the state of health of the child. Thus 
they are even more unmanageable than in their ordinary form, in con- 
sequence of the repeated cerebral congestions ; they may either partially 
suspend the cough, i. e. diminish its frequency, but not its violence, or, 
by adding force to the spasm, death by suffocation may be the result of 
the sudden closure of the larynx ; or, lastly, if the child have been 
harassed and broken down by hooping-cough for some time previously, 
the constitution will offer but little resistance to the secondary attack. 

With regard to the distinction between convulsions and hydrocepha- 
lus, occurring as secondary affections, it does not appear easy, nor do I 
deem it very important, and therefore I have grouped them together. 
It is almost certain that if the convulsions continue for any length of 
time without proving fatal, they will terminate in hydrocephalus. My 
experienced friend, Dr. Johnson, observes, in his excellent essay, " It 
is said that in hydrocephalus one side of the body is more affected than 
the other ; but in convulsions, which are independent of organic disease 
of the brain, that both sides are equally affected. If the convulsions 
are confined to one side of the body, there is every reason to fear the 
existence of hydrocephalus; but it certainly does not follow, because 
the convulsions are general that the brain is unaffected. In the latter 
case we must wait till the convulsions subside before we can discover 
their cause, and then we must form our opinion from the general state 
of the child, and the history of the case, rather than from any peculi- 
arity in the convulsion itself." 1 

1 Cyclop, of Pract. Med., vol. ii. p. 431. 



PERTUSSIS. 241 

852. IV. Pertussis complicated with Apoplexy. — We have already 
seen that fatal apoplexy may occur from excessive congestion of the 
brain : it cannot, therefore, surprise us to find, in a disease involving 
such frequent congestion of the vessels of the head, that occasionally 
cases occur in -which the vascular fulness produces not merely convul- 
sions, but a true apoplectic attack. 

The same result may take place from a higher degree of pressure, 
under which the texture of the vessels gives way, and effusion of blood 
takes place between the membranes, or into the cerebral substance. 

Although this appears a natural result of the pressure exercised upon 
the brain by the repeated force of the cough, it does not seem to be a 
frequent complication, unless we suppose that the sudden deaths on 
record are really such cases. It is mentioned by Marley 1 and others : 
and I shall quote a case from Barrier, as illustrating the mode of attack, 
and in some degree countenancing the suggestion I have just made, that 
some at least of the sudden deaths may have been owing to sanguineous 
apoplexy : — 

"Claude Charmillon, set. 17, had suffered six weeks from hooping- 
cough, when admitted into the Hopital des Enfans, May 5, 1848. The 
first stage had lasted about fifteen days, and for a month past the cough 
had been accompanied with hoop, and followed by vomiting of glairy 
matters, more frequent during the night than the day, free from com- 
plications, and the condition good during the intervals. 

''During the first few days he was under M. Barrier's observation, 
the cough was forcible and frequent, sometimes followed by epistaxis. 
Auscultation gave evidence of fluid in the bronchial tubes. May 9. 
The patient, being feverish, was bled. May 10. Considerable catarrh. 
May 11. Slight eruption of scarlatina. After this the eruption con- 
tinued quite as usual, but the bronchitis increased, and the bleeding was 
repeated with benefit. But the patient became emaciated, and phlebitis 
set in where the vein had been punctured, and two abscesses formed in 
the fold of the arm. The hooping-cough had necessarily diminished, 
when, in the night of the 31st May, the patient died suddenly, after a 
severe fit of coughing. On making a post-mortem examination, the lungs 
were healthy, the bronchial mucous membrane inflamed. The bronchial 
and thymus glands, the head, and abdominal viscera, were healthy ; but 
on opening the cranium, a great effusion of blood was found in the cavity 
of the arachnoid, covering the convexity, and also at the base of the right 
hemisphere of the brain and cerebellum, with some blood infiltrated 
between the pia mater and arachnoid of the same side." 2 

The symptoms, then, which ought to excite alarm, are a continuance 
of the congestion about the head and face, unusual drowsiness, &c. ; 
and we find that the attack may either occur suddenly, proving instantly 
fatal, or the drowsiness may degenerate into stupor and coma, equally 
fatal, but less rapidly so. Though not a frequent complication, it is in 
all cases a most serious one. 

353. Pathology. — We have very rarely any opportunity of examining 
the condition of the organs engaged in simple hooping-cough, on account 

1 Diseases of Children p. 159. 2 Mai. de l'Enfance, vol. i. p. 381. 

lb' 



242 PERTUSSIS. 

of its rarely proving fatal, unless complicated, and then there is danger 
of mistaking, as many have done, the effects of the latter for the former. 
It is only when the child dies from some other disease, or from some 
distant complication, that we can ascertain the real condition of the 
lungs. 

In such cases, there is most frequently no trace at all of disease in 
the larynx, trachea, or lungs ; in other cases there is slight vascularity 
of the mucous membrane of the glottis and larynx, and sometimes sub- 
mucous oedema of these parts. 

When the cough has been violent, we may occasionally discover some 
interlobular emphysema, owing to the rupture of some of the air-cells, 
and, though rarely, this emphysema has extended to the surface. 

Ulceration of the glottis and in the larynx and trachea have been 
mentioned by Astruc, Mackintosh, and Alcock. 

The bronchial tubes are found more or less filled by mucus, and 
occasionally by muco-purulent fluid. 

My friend Dr. Hess informs me, that in several cases of hooping- 
cough, which proved fatal from lobular pneumonia, and which he ex- 
amined with Mr. Friedleben, they found an enlargement of the bronchial 
glands, so that pressure on the nervus vagus and the recurrens seemed 
not unlikely. 

354. In fatal cases from any of the complications, the usual post- 
mortem appearances are discovered. In bronchitis or pneumonia there 
is vascularity of the lining membrane of the air passages, muco-purulent 
secretion, congestion, and hepatization of the lung. 

Simple convulsions generally leave no trace, or merely an unusual 
degree of vascularity. 

When the child has been attacked by hydrocephalus, the usual evi 
dences have been found : extreme vascularity of the membranes, 
congestion of the vessels of the cerebrum and cerebellum, effusion of 
serum, tubercular deposition, &c. 

And in cases complicated by apoplexy, extreme congestion and vas- 
cularity of the substance of the brain, or sanguineous effusion, as in M. 
Barrier's case. 

Thus the rarity of opportunities for examining cases of simple hoop- 
ing cough after death, and the fact that, in those which have been exa- 
mined, some of the appearances I have enumerated have been found, 
has misled many observers as to the essential nature of the disease, and 
given rise to very various and contradictory views on the subjects. 

355. Linnaeus maintained that it arose from inhaling, in respiration, 
the minute eggs of a peculiar species of insect ; ! and his view, somewhat 
modified, was advocated by Riverius, Dessault, Rosenstein, &c. 

Hoffmann attributed it to an acrid serum in the blood ; Sydenham to 
some irritating effluvia cast off from the blood into the lungs, in conse- 
quence of suppressed transpiration. Huxham thought it was owing to 
a morbid condition of the intestinal canal ; Butter that it depended 
upon derangement of the liver ; Waldschmidt and Stoll that it was 
caused by crude and bilious matter in the stomach. 

1 Diss. Exanth. viva in Amcenit. Acad., vol. v. p. 82. 



PERTUSSIS. 243 

Dr. Watt, judging from the results of his post-mortem examinations, 
attributes it in all cases to inflammation of the bronchial tubes, either 
so mild as to cause no inconvenience, or so severe as to cause death. 

Mr. Dawson limits the inflammation to the mucous membrane of the 
glottis and larynx. Dr. E. Watson considers the pharynx and larynx 
to be involved with peculiar irritability of the glottis. 1 MM. Marcus, 2 
Broussais, Boisseau, Guersent, Rostan and Duges, regard it as a spe- 
cific inflammation of the bronchi. 

M. Danz places the seat of the disease in the lungs, and Strong, Cul- 
len, Astruc, Lettsom, and Darcy, mention having found evidences of 
inflammation of the mucous membrane of the larynx and trachea. 

Dr. Webster considers the hooping-cough as essentially a cerebral 
disease ; he found, on examination, the hemispheres of the brain very 
vascular, the convolutions almost obliterated, serous effusion, &c. 3 

M. Lobenstein Lobel met with a case in which a considerable portion 
of the diaphragm was covered with pustules. 

Dr. Alcock states that he found the larynx invariably inflamed, and 
sometimes so much so as to close the glottis mechanically, that the 
mucous membranes of the trachaea and bronchi were very vascular, and 
that the cavities of the latter were filled with fluid mixed with air. 4 

M. Alph. le Roi agrees with Dr. Webster that hooping-cough should 
be classed among diseases of the membranes of the brain. 

M. Gilbert considers the disease as essentially nervous or spasmodic, 
the cough being caused by a spasmodic affection of the glottis and 
diaphragm. 

Inflammation of the pneumogastric nerves has also been regarded as 
the essential cause of hooping-cough. It has been observed twice by 
MM. Breschet and Autenrieth, and fifteen times by Kilian ; but not- 
withstanding the most careful dissection, MM. Jadelot, Guersent, 
Baron, and Billard, could discover none. M. Albers, of Bonn, out of 
forty-seven cases, found that in forty-three the nerve was healthy : in 
one it was reddish on the left side, and in three on the right side. 5 

The late Dr. Sanders, of Edinburgh, considered congestion at the 
origin of the pneumogastric and other respiratory nerves to be the essen- 
tial pathology of hooping-cough, and Dr. S. Piddock adopts this opinion 
and bases his treatment of this disease upon it. 6 

Laennec admits that the suspension of inspiration may be owing 
either to congestion of the mucous membrane or to spasm, and that the 
larynx and bronchige are affected. 

Dr. Alderson makes the disease to consist in inflammation of the 
lungs. 7 

Dillon, Hufeland, Lobel, Breschet, Albers, and Eberle, s regard it as 
a nervous disease, perhaps of the brain, or perhaps of the pneumogas- 
tric nerve. 

Desruelles says that "hooping-cough is nothing more than bronchitis 

1 Dub. Med. Press, Feb. 1850. 

2 Traite de la Coqueluche, 1816 ; trad. par. M. Jacques, p. 67. 

3 London Med. and Phys. Journal, vol. xlviii. 

4 Lectures on Surgery, p. 132. 

6 Roe on Hooping-cough, p. 57. 6 Lancet, June 16, 1849. 

7 Med. Chir. Trans., vol. xvi. part 1. s Diseases of Children, p. 479. 



244 PERTUSSIS. 

complicated with irritation of the brain ; and that the inflammation of 
the bronchise is always primitive, the irritation of the brain consecutive. 
So long as the bronchitis is simple, the cough is without any peculi- 
arity ; but when the diaphragm, muscles of expiration, and of the 
glottis, larynx, and posterior membrane of the bronchise and the air 
cells of the lungs, come into action, and are simultaneously affected 
with spasm, under the influence of the cerebral irritation, the cough 
changes its character, and becomes convulsive ; and every time that an 
afflux of blood takes place into the brain, the cough returns, and appears 
in paroxysms." 1 

M. Blache is of opinion " that hooping-cough is a nervous affection, 
having its seat both in the mucous membrane of the bronchige, and in 
the pneumogastric nerves : an affection very frequently complicated 
with bronchitis and pneumonia, but which may exist without them ; and, 
like all other diseases of the same kind, having no appreciable anatomi- 
cal character." 2 In this opinion Dr. Roe, MM. Barrier, 3 Rilliet and 
Barthez, 4 and many of the more recent writers, coincide. 

Dr. Copland considers the "medulla oblongata, or its membranes, to 
be early implicated in this disease; evidences of inflammatory irritation 
of these parts having been very generally observed in the post-mortem 
inspections I have made. I conceive that the morbid impression or irri- 
tation occasioned by the exciting cause in the upper parts of the respi- 
ratory surfaces, particularly the glottis and its vicinity, affects the res- 
piratory nerves, especially the pneumogastric; and that the irritation 
is extended to the origin of the nerves, when it aggravates and perpetu- 
ates the primary affection." 5 

Dr. James Duncan has recently proposed to class hooping-cough with 
exanthematous diseases, a view which was formerly broached by Volz, 
the resemblance having been already noticed by Jos. Frank. The es- 
sence of the disease, according to Dr. Duncan, consists in turgescence 
of the bronchial glands, coinciding with or arising from a peculiar fever, 
and the result of a specific poison ; and acting upon the pneumogastric 
nerve, in the way Dr. Ley supposed in the case of spasm of the glottis. 6 

Dr. Fyfe, in a late paper, looks upon the disease as a neurosis alto- 
gether distinct from bronchitis, and he affirms that the two diseases can- 
not co-exist. 7 

356. It would have been very easy to have multiplied conflicting 
opinions; for most writers, having pre-conceived opinions of the school 
in which they had been educated, were prepared to view the disease in 
a certain light. Thus the humoral pathologist saw in it some peculiar 
acrid quality of the fluids, and the morbid anatomist mistook the results 
of a post-mortem examination for the active pathology of the affection, 
and both were undoubtedly in error. 

The different views of the nature of the disease may be thus summed 
up: — 

1 Traite de la Coquelucke, p. 77. 

2 De la Coqueluche. Archiv. Gen. de Med., 1833, vol. ill. , second series. 

B Mai. de l'Enfance, vol. i. p. 39. 4 Mai. des Enfans, vol. ii. p. 228. 

5 Diet, of Med., Part v. p. 242. 

6 Dublin Quarterly Journal of Medical Science, &c, Aug., 1847. 

7 Prov. Med. and Surg. Journ., June 16, 1847. 



PERTUSSIS. 245 

1. That it consists simply in inflammation of the mucous membrane 
lining the air-passages, the glottis, larynx, trachea, bronchial tubes, and 
air-cells. 

2. That this inflammation is of a specific character. 

3. That it is an affection either of the pneumogastric nerves, spinal 
nerves, medulla spinalis, the brain, or the nervous system generally; 
either of a nervous or inflammatory character, or a reflex irritation. 

4. That it is a compound affection : in the beginning an inflammation 
of the air-tubes, and subsequently a spasmodic or nervous affection. 

5. That it is a nervous affection, having its seat in the bronchial mu- 
cous membrane, and in the pneumogastric or other nerves. 

357. Now, if we are to decide the question by the results of post- 
mortem investigations, we must necessarily conclude that none of these 
theories can be the true one, because the facts upon which they are 
based are by no means sufficiently general ; some indeed are so rare 
that it is evident they are additions to the primitive disease, and others 
so very uncommon that one must conclude that they have nothing at 
all to do with it. 

Again, if we analyze minutely the history of the disease, and com- 
pare many cases together, we must arrive at the conclusion that they 
are divisible into two great classes, the simple and the complicated, and 
these differ, not merely in degree, but in kind ; that the former present, 
upon the whole, a very uniform appearance, with similar stages, symp- 
toms, and course; but that the latter possess additional symptoms, of 
different kinds, by which their history is altogether modified; they are, 
in short, hooping-cough, plus the peculiar complication of each. This 
is so evident that the best modern authorities have based their descrip- 
tion of the disease upon it. 

On this ground we must reject those post-mortem evidences of exten- 
sive bronchitis, pneumonia, arachnitis, congestion of the brain and spinal 
marrow, redness and swelling of the pneumogastric nerves, &c, as being 
foreign to cases of simple hooping-cough ; and if we then proceed to 
the consideration of the question of the nature of the disease, we find 
very little assistance to be obtained from morbid anatomy, for in the 
majority of cases of death from other affections during hooping-cough, 
the air-passages exhibited little or no trace of disease. 

If we turn to the history of the disorder, we find that it generally 
commences by a catarrhal affection of the mucous membrane of the 
eyes, nose, and air-passages, amounting, in some cases, to actual bron- 
chitis; but it may be doubted how far this must be considered essential 
to the disease, inasmuch as many cases occur in which it is altogether 
absent. And as this affection subsides, in its place we have a peculiar 
spasmodic cough, consisting of a series of forcible succussions during 
expiration, with an impossibility for a time of making a complete inspi- 
ration. This impediment to inspiration evidently arises from spasmodic 
action of the muscles of the larynx, trachea, and bronchial tubes, 
extending probably to the smallest, as it comes on quite suddenly and 
subsides as suddenly. And although the cough is excited by the pre- 
sence of mucus, and has for its object its removal, yet its character is 
peculiarly spasmodic and unlike any ordinary cough. 



246 PERTUSSIS. 

Now, without attributing it to organic disease of the brain or spinal 
marrow, we cannot but refer the peculiarity of this cough and hoop to 
a state of the nervous system analogous (shall I say) to that which 
gives rise to spasm of the glottis — in other words, that hooping-cough 
is also a case of reflex irritation of the nervous system, excited, no 
doubt, by other and different causes, but exhibiting a similar transfer- 
ence of effects. 

We are at present, I believe, quite ignorant of the nature of the 
peculiar exciting cause. We know that it exists, and that when it is 
applied the primary irritation of the mucous membrane arises, followed 
by the reflected nervous irritation which gives rise to the peculiar phe- 
nomena of the disease. 

358. Causes. — I have already mentioned that this disease is most 
common in infants and children, though not absolutely confined to 
them ; and although, doubtless, the chief cause of this is, as Dr. Watts 
observes, "that few individuals can pass many years of their lives with- 
out being so much exposed to the contagion as to bring on the disease," 
yet there does appear to be something in the constitution of children 
which renders them peculiarly susceptible to its influence. 

Dr. Butter observes that " the nervous system bears a much larger 
proportion to the other solid parts in children than in adults ; the solid 
parts are likewise of a much softer texture and of a much quicker 
growth; the human body is then endued with much more irritability 
than at any other period of its existence," and consequently more easily 
affected. 

"One can hardly doubt," says M. Gendrin, "that, owing to the 
development and extreme activity of the circulation, and the permea- 
bility of their tissues, that infants are in the most favorable state for 
the absorption of miasmata." 

On these grounds, it has been attempted to explain the fact that more 
girls have the disease than boys. 

Climate has much influence upon the mortality in the disease, though 
little, if any, upon its presence and extension. It is very prevalent and 
very fatal in northern regions ; less frequent and much less severe in 
the south, as a general rule, to which, however, there are exceptions, as 
in the fatal epidemic of 1808 in Madeira. 

In these countries, it appears more frequent in winter and spring ; 
and, according to Dr. Watts's tables, March was the most fatal month, 
and July, August, and September the least. 

The agency of a cold and moist atmosphere in the production of the 
disease is much insisted upon by Richter, Marcus, Desruelles, &c. It 
appears also to be in some way connected with other epidemics, often 
appearing just before, during, or immediately after an epidemic of 
measles or influenza. 

359. Now and then we meet with single cases of hooping-cough ; but 
such are comparatively rare, for the disease almost invariably spreads 
through a town or village, either by epidemic influence or by contagion. 

No one questions the occurrence of the disease as an epidemic ; it 
has repeatedly spread thus over extensive districts, and proved most 
fatal. 



PERTUSSIS. 247 

De Thou, Sermert, Sauvages, Riverius, &c, notice epidemics as 
occurring in 1510, 1557, 1580, 1757, 1767, and 1769, and many of 
them spreading over a great part of Europe. 

According to M. Desruelles, 1 Pasquier mentions an epidemic of this 
kind in 1411, in Paris, which attacked more than one hundred thousand 
people. De Thou and Sennert mention another in the same city in 
1510 ; Riverius one that spread almost over Europe in 1557 ; Baillou 
one in 1578. In Sweden, Rosen has noticed their prevalence from 1749 
to 1764, during which 43,398 deaths occurred. Geller one in 1757, 
in the duchy of Magdeburgh ; Arand one that occurred in Mayence, in 
1769 ; Aaskou one that happened at Copenhagen, in 1775. 

Dr. Willey mentions that in 1805 it was introduced into Block Island, 
and prevailed epidemically. 2 

Dr. Tretis that it was epidemic in Madeira in 1808, 3 and proved very 
fatal. 

In 1817, it is said by Marcus to have been epidemic in Milan and at 
Bamberg. 

Since then, partial epidemics, with which we are all familiar, have 
occurred, limited generally to a city or town, but occasionally spread 
over a tract of country more or less extensive. 

No doubt the characters of these epidemics, and especially of the 
complications of hooping-cough, differed very much. Thus sometimes 
the patients were attacked by epistaxis, sometimes by convulsions : in 
other cases by eruptive fever, or by some visceral inflammation, as is 
recorded by Ozanam. 4 

360. It must always be extremely difficult, if not impossible, abso- 
lutely to prove the contagiousness of an epidemic disease, inasmuch as 
proximity or contact involves also exposure to the same atmospheric 
influence. Nevertheless, there are diseases which prevail epidemically 
(smallpox and measles, for instance) which are admitted by all to be 
contagious, and among them we must class hooping-cough. No doubt 
its great extension is as an epidemic ; but yet we see now and then cases 
which appear to be fairly communicated from one person to another, as, 
for example, in the case related by Barrier, of children who caught the 
disorder at a day-school, and, being confined at home by it, communi- 
cated it to their father and mother, 5 and those related by Duges. 6 

The weight of opinion is certainly in favor of its being propagated 
by contagion. On this side we have the authority of Cullen, Sims, 
Hillary, Watt, Hamilton, Underwood, Dewees, Eberle, Stewart, John- 
son, Roe, Barrier, Dug&s, &c. 

Laennec, Desruelles, and others, have expressed a doubt of this being 
the case, and others have altogether denied it ; but to my mind the 
evidence is conclusive. 

361. Diagnosis. — We must always take into consideration the posi- 
tive and negative evidence in forming our judgment. The most strik- 
ing characteristics of the disease are the subsidence of the catarrhal 

1 Traite de la Coqneluche, p. 100. 2 American Med. Repos., toI. x. p. 95. 

3 Med. and Phys. Journ., vol. xxiii. p. 100. 

4 Barrier, Mai. de l'Enfance, vol. i. p. 372. 5 Ibid., vol. i. p. 373. 
6 Diet, de Med. et de Chir. Prat., vol. v. p. 488. 



248 PERTUSSIS. 

and setting In of the spasmodic stage, with the remarkable kink and hoop. 
It is not very easy to mistake either; but I must recall to my readers 
■what I have mentioned before, that the hoop is not always present, and 
also that in very young infants a common cough is often accompanied 
by an occasional hoop, if they are at all alarmed by the cough. 

The kink, however, is almost never absent (both cannot be absent 
together, of course, or the case would not be hooping-cough) ; and the 
series of forcible and rapid succussions, without intervening inspiration, 
is observed in no disease that I know of, to the same extent, except 
asthma, which is not an affection of childhood. 

No doubt, in some forms of bronchitis there is a paroxysmal charac- 
ter of cough, kinks of coughing,"in fact, though different from those of 
hooping-cough. Rilliet and Barthez have laid down the differences 
very distinctly. In pertussis we have the catarrhal stage generally 
preceding the kink ; in bronchitis the paroxysm of coughing is coinci- 
dent with the commencement of the disease. In pertussis we have the 
hoop, the glairy tenacious expectoration and almost always vomiting ; 
in bronchitis the kinks are shorter and less intense, no hoop, but little 
expectoration, and no vomiting. In simple pertussis there is little 
fever, no hurry of respiration during the intervals, and the respiratory 
murmur pure ; in bronchitis the fever is intense, the respiration hurried 
and increasing in frequency, rales sibilant and mucous, afterwards sub- 
crepitant. In pertussis the kinks continue for a time, then decrease 
until the cough becomes simple, and the child convalescent; in bron- 
chitis the smallness of the pulse, the extreme dyspnoea, paleness of face 
persist or increase, and the disease almost always terminates fatally. 1 

362. Prognosis. — In simple hooping-cough there is comparatively 
little danger, the principal risk being from exhaustion, or from the set- 
ting in of some of the diseases already mentioned as following upon 
hooping-cough in delicate, broken down children. Young infants, even, 
who are carefully nursed, go through the disease very well. 

But in epidemics, because of the complications, and in single cases 
which are complicated, the danger is very great, and the mortality very 
high. In the epidemic of 1580, 9000 children are said to have died at 
Home. 

In Sweden, from 1749 to 1764, Rosen states that 43,393 deaths oc- 
curred from this disease, and of these, 5832 occurred in the year 1755. 

Dr. Armstrong mentions that from 1769 to 1777, 732 cases oc- 
curred at the dispensary for the infant poor, and that twenty-five died. 2 

Dr. Watt mentions that on the whole the deaths from hooping-cough, 
in Glasgow, amount to five or five and a half per cent, of the entire. 
deaths in the city ; and that in 1809 they amounted to 259, or more 
than eleven and a half per cent. 3 

In Prussian Pomerania the deaths were as 1 to 25J of the entire 
mortality; in Denmark, as 1 to 21J; in Brandenburg, as 1 to 29J ; in 
Sweden and Finland, 1 to 13 J ; in Strasburg, 1 to 94 ; in Boston, 1 to 

1 Mai. des Enfans, vol. ii. p. 223. 

2 An Account of the Diseases most incident to Children, p. 142. 

3 On the Chin-Cough, p. 24. 



PERTUSSIS. 249 

82 ; in Charleston, 1 to 46.6 ; in Baltimore, 1 to 95.38 ; in New York, 
1 to 64.7 ; and in Philadelphia, 1 to 63. 1. 1 

In the admirable Report upon the Population Census of Ireland, 
Mr. Wilde states the mortality from hooping-cough to have been 36,298 
in ten years, in the proportion of 100 males to 115.43 females. " It 
has proved most fatal in the rural districts, being there in proportion to 
all other diseases as 1 in 30.48, and to those of the epidemic class as 
1 to 9.09 ; while in the civic districts it is 1 in 36.76 of the deaths 
from all other causes, and 1 in 14.04 of those denominated epidemic 
or contagious. Its general mortality, in comparison with all other af- 
fections, for the entire kingdom, is 1 in 32.71, and of the total epi- 
demic diseases, 1 in 10.5. In the metropolis, this affection was to the 
total epidemics, 1 in 17.47 ; in the province of Leinster, 1 in 12.24 ; in 
Munster, 1 in 11.24 ; in Ulster, 1 in 9.4; and in Connaught, 1 in 9.1." 2 

363. With such evidence of the fatal results of the disease, it will 
become us to inform ourselves most carefully as to the age, constitution, 
previous health, and the actual state, not merely of the lungs, but of 
every organ of the body, before giving our prognosis ; and even then it 
will be wise to be very guarded, and to watch well for the first symptoms 
threatening any of the complications. 

The symptoms which justify a favorable prognosis are the paroxysms 
being distant, with intervals of complete relief and quiet respiration, the 
rest at night not much disturbed, the appetite good, no local complica- 
tions, and the absence of fever. The unfavorable symptoms are, fre- 
quent and violent cough, hurried respiration, dyspnoea, fever, loss of 
sleep and appetite, and any indication of local complication. 

364. Treatment. — As it is generally admitted that hooping-cough will 
run its course notwithstanding all our efforts, it is pretty clear that but 
little treatment, and that palliative, is necessary in the milder cases. 
During the first stage, a gentle antimonial emetic may be given, followed 
by an expectorant every four or six hours, with a dose of aperient medi- 
cine, and a repetition of the emetic occasionally, a warm bath at bed- 
time, and confinement to a warm, equable temperature. I would also 
remark that in different epidemics different remedies seem to succeed. 
Some formerly successful, seeming to lose their power, and when this is 
the case it is right to suspend their use and have recourse to others. 

Burton, Millar, Lieutaud, and others, deprecate blood letting, and 
certainly, unless the disease be complicated, or the first stage set in with 
considerable violence, it is quite unnecessary ; but in the latter case, 
loss of blood will lower the fever, relieve the catarrhal oppression, and 
render the second stage milder ; but the amount should be carefully 
regulated, and be rather under than over the mark. Willis, Sydenham, 
Lettsom, Dewees, Duges, &c, recommend the abstraction of blood under 
these conditions. Dr. Pidduck, in accordance with his views of the pa- 
thology of the disease, advises leeches directly over the junction of the 
occiput and the atlas vertebra, followed by a blister between the shoul- 
ders, and he speaks most strongly of their good effects if the disease be 
uncomplicated. 

1 Condie on Diseases of Children, p. 3G7. 

2 Report upon the Tables of Deaths, p. 15. 



250 PERTUSSIS. 

The use of emetics of tartarized antimony was first recommended by 
Dr. Armstrong, who had employed them "for eighteen years with very 
good success," 1 and they have since been advised by the highest authori- 
ties. They may be given, as I have said, at the commencement, and 
repeated occasionally. 

A mixture with ipecacuanha wine, syrup of squills, a little syrup of 
white poppies, and almond milk, or mucilage and water, will answer very 
well as an expectorant ; or we may give Coxe's hive syrup, as recom- 
mended by Dewees, which is made by boiling half a pound of senega 
root and dried squills, in eight pounds of water, over a slow fire, until 
half is consumed, and then adding to the strained liquor four pints of 
strained honey, and again boiling down to six pounds, and adding a 
grain of tartar emetic to each ounce. The dose must be regulated ac- 
cording to the age of the child, from six to eight drops or upwards, every 
hour or two. 2 

Probably the best aperient medicine is castor oil or rhubarb, magnesia 
and ginger ; and the frequency of its administration must be regulated 
by the state of the bowels, which should be well evacuated. 

The diet should be bland, and, if there be much fever, confined to 
milk and vegetables ; if otherwise, a little chicken broth may be allowed. 

365. During the second stage, marked by the peculiar cough and 
hoop, the tenacious mucus, and the absence of fever, we shall find it 
beneficial to continue the emetics occasionally, and also the expectorant 
medicine ; but in addition it will be necessary to employ some antispas- 
modic remedy for the relief of the paroxysm. 

Probably the most common is opium in some form. A few drops of 
laudanum may be added to the expectorant mixture, or we may adopt 
Mr. Pearson's 3 plan, who, after an emetic, prescribed one drop of lauda- 
num, five drops of ipecacuanha wine, and two grains of carbonate of 
soda, every fourth hour. As the cough subsided, he diminished the opiate, 
and substituted gum myrrh for the ipecacuanha wine. 

Dr. Dewees recommends a combination of paregoric, antimonial wine, 
liquorice, gum Arabic, and water, as a mixture, and I can add my testi- 
mony, if it be necessary, to its value. Lombard recommends the syrup 
of white poppies, Condie the watery extract of opium, and others Dover's 
powder. 

There is no reason, however, for believing that opium will cure the 
disease, but it renders the paroxysms less severe and composes the 
patient. 

Hemlock is highly recommended by the older writers. Dr. Butter, 
in 1772, praised it as a specific. Dr. Armstrong tried it in 357 cases, 
of whom seventeen died, but nine of these, he says, were unfavorable 
cases. 4 The formula he employed was this : — 

R. — Extr. cicutse gr. x. 
Aq. purse, 

Aq. nienth. pip., aa ^iv. 
Sacch. alb. ad grat. sapor, q. s. — M. 



1 On the Diseases most incident to Children, p. 50. 

2 On Diseases of Children, 437. 

3 Med. Chir. Trans., vol. i. p. 25. 4 On Diseases of Children, p. 142. 



PERTUSSIS. 251 

A dessertspoonful was given to an infant six months old, every four 
hours ; three teaspoonfuls to a child of a year ; and a tablespoonful to 
one of two years of age. 

Dr. Gurnprecht speaks most highly of the extract of the lactuea 
virosa in the second stage. He advises half a grain, with sugar, three 
times a day, for children of two years of age. 1 

Acetate of lead has been highly praised by Dr. Reece. 2 He pre- 
scribed the following mixture : Four grains of the acetate of lead, two 
drachms of syrup of violets, and two ounces of water ; of which he gave 
to a child four years old a teaspoonful every six hours, increasing the 
dose to two teaspoonfuls the following day. 

But perhaps the most influential narcotic and sedative we possess is 
the belladonna ; it has been very extensively employed, and the evidence 
in its favor is very strong. Hufeland, Jackson, Guersent, Blache, 
Stewart, Condie, &c, speak highly of it. As it is very powerful, and 
somewhat uncertain, we should begin with small doses, and watch it very 
closely. From one-quarter of a grain to one grain of the powdered 
root, and from one-eighth to one- half a grain of the extract, may be 
given two or three times a day. Dr. Jackson advises that one-sixth of 
a grain should be given to a child of three months old, every three 
hours; to a child of two years old, one grain; and to a child of four 
years, a grain and a half in each dose. 3 Jackson, Guersent, and Blache 
recommended its continuance until the effect upon the pupil is evident ; 
it may then be discontinued. 4 

Kahleiss gave it in combination with Dover's powder, and between 
each dose a mixture containing prussic acid. M. Trousseau combines 
it with opium and valerian. M. Guersent recommends equal parts of 
henbane, belladonna, and oxide of zinc; of the latter he gives one grain 
every hour to a child of six months old. 

M. Caron du Villard derived great benefit from laurel water, in doses 
of six drops every two hours. Dr. Krimer, of Halle, and Dr. Brofferio, 
recommend the inhalation of its vapor. 

Hydrocyanic acid was first used, I believe, in hooping-cough, by 
Fontaniottes and by Coullon, in 1808, and since by Heineken, Behr, 
Kahleiss, Muhrbeck, &c. It was introduced into this country as a 
remedy in this disease, by Dr. Granville, in 1819 ; and has been tried 
successfully in America, by Drs. Edwin Atlee, Stewart, Condie, and 
others. Dr. Roe has found it most valuable in checking and cutting 
short the spasmodic stage. 

I have tried both the laurel water and the acid repeatedly, and the 
latter certainly with great benefit, though it failed in many cases to 
shorten the disease. 

" The dose of hydrocyanic acid," says Dr. Roe, " for an infant, is 
about three-quarters of a minim, of Scheele's strength, gradually in- 
creased to a minim, which may be given every fourth hour ; for a child 
of three years of age, about one minim, gradually increased, if neces- 

1 Med.-Chir. Trans., vol. vi. p. 608. ~ 2 Med.-Chir. Rev., vol. xv. p. 37. 

3 American Journal of Med. Science, Aug. 1834. 

4 Barrier, Mai. de l'Enfance, vol. i. p. 392. 



252 PERTUSSIS. 

sary, to a minim and a half every fourth hour ; for children of ten or 
twelve years of age, a minim and a half, increased to two minims every 
fourth hour. It is safer to give this medicine in small doses, at very 
short intervals, than to run any risk of producing too great a depression 
by a large dose. The frequency of its exhibition must depend upon the 
strength of the patient and the severity of the attack. The dose should 
be repeated when the effects begin to subside, which in mild cases gen- 
erally happens in three or four hours ; but when much fever is present, 
its influence is felt but a very short time : under such circumstances, a 
larger quantity may be given, and at shorter intervals, without any 
apprehension of danger, so long as the fever lasts. In some very severe 
cases, when the pulse was up to 120, with a good deal of fever, and a 
very hot skin, I have given to a girl of ten years of age a minim and a 
half of this medicine every quarter of an hour for twelve hours ; at the 
end of twenty-four hours she was free from fever, and her strength was 
not in the least reduced by the effects of the remedy. As some catarrhal 
symptoms are generally present, a few drops of ipecacuanha or antimo- 
nial wine may be advantageously combined with the hydrocyanic acid ; 
but the latter alone possesses the power of curing this formidable com- 
plaint." 1 

I would suggest that this medicine should always be given in draughts, 
and not in a mixture, because then only can we be quite sure that the 
child will not get an overdose. I have found almond milk an excellent 
vehicle. 

Other narcotics have been recommended, but I need hardly occupy 
the reader's time with them ; I will only add a general observation or 
two ; and first, that as narcotics have the effect of diminishing secretion, 
that effect should be corrected by some expectorant, or the original te- 
nacity of the mucus of the second stage will be increased, and its expec- 
toration rendered more difficult ; secondly, that (with the exception of 
the prussic acid) narcotics are of less efficacy in proportion to the 
amount of fever, and it is when that has subsided that they possess so 
much power over the spasm ; and, lastly, as they also constipate the 
bowels more or less, we must counteract this effect by an occasional pur- 
gative. 

Among the antispasmodic remedies we find also assafoetida, castor, 
musk, valerian, sal ammoniac, &c, highly recommended, and which may, 
perhaps, in some cases be useful, but which are evidently inferior to the 
narcotics. • 

366. Variations in the mode of administering narcotics and anti- 
spasmodics have been adopted. Mr. Warren recommends liquid lauda- 
num to be rubbed on the abdomen and pit of the stomach daily. Mor- 
phia, applied to a blistered surface, has been useful, according to Brendt 
and Meyer, of Minden, who state that five cases were so much relieved 
by it in eight days as to require no further treatment. Embrocations 
consisting in part of laudanum, have been very long employed with 
benefit. 

Another mode is by inhalation. Marley mentions that he has known 

1 On Hooping-Cough, p. 89. 



PERTUSSIS. 253 

"inhaling the steam of a decoction of the fresh leaves of hemlock, alone 
or with ether, to be of use." 1 Dr. Stewart mentions that fumigation 
with the vapor of benzoin was accidentally discovered, a few years since, 
to allay, with remarkable quickness, the paroxysms of hooping-cough. 2 
Dr. Watt and Mr. Waddington 3 have used the vapor of tar with success ; 
and it is said that relief has been afforded by the fumes of warm spirits 
of turpentine. M. Paterson made some experiments with the nitrous 
ether, but I do not know that they were very successful. 

Soon after the discovery of the anesthetic effects of sulphuric ether, 
it struck me that it would be likely to modify or suspend the spasm in 
hooping-cough ; and, having a case under my care, I directed that a 
little (I suppose about half a drachm) should be spilled upon the nurse's 
hand and held before the child's nose and mouth at the commencement 
of a fit of coughing. I preferred this simple mode of administration 
(and do still) because of the impossibility of thereby giving an overdose. 
The effect surpassed my expectation. Most generally, the paroxysm 
was shortened more than one-half, often stopped immediately, and the 
duration of the disease unquestionably considerably diminished. Since 
then, I have tried the ether in twelve or fourteen cases, and chloroform 
in six. In one or two cases, no benefit accrued ; in others, great mitiga- 
tion of the spasm ; and in three or four almost complete relief when 
the ether was applied at the beginning of a fit of coughing. Decidedly, 
also, in two-thirds of the cases, the course of the disease was much 
shortened, so that I look upon this as a valuable addition to our reme- 
dies. In no instance was insensibility or the least inconvenience occa- 
sioned. 

There are two obstacles to its fair administration to young children ; 
1, they do not give notice of the approach of the cough, so that by the 
time the chloroform is ready the paroxysm has commenced, and, as that 
consists of expirations mainly, the chloroform will have evaporated 
before its full effect is produced ; 2, young children resist any apparent 
impediment to free respiration, as a hand placed before their mouth. I 
have, however, had an opportunity of trying it in four cases of young 
persons above sixteen years of age. In two (girls), in whom the hoop 
was fully developed, it arrested it at once; and, after using it for two 
days, the hoop entirely disappeared, a trifling cough only continuing 
for some time. In a third (girl), it was used from the commencement. 
It immediately stopped or prevented the hoop, and always relieved 
the tickling preceding the cough ; and, after using it three or four 
times a day for three weeks, the disease disappeared. She never lost 
appetite or sleep, vomited only once or twice, and was never distressed 
by the cough. Her brother, who had the disease most severely, 
also took chloroform, and it reduced the paroxysms more than one-half 
in number during the twenty-four hours, without diminishing their 
intensity ; but, as it seemed to make him stupid, it was suspended, and 
prussic acid given, under which treatment the disease was cured in a 
month. 

1 Diseases of Children, p. 163. 2 Diseases of Children, p. 109. 

Lancet, June 21, 1845. 



254 PERTUSSIS. 

In 1797, Mr. W. Simmonds, of Manchester, recorded his experience 
of the great value of arsenic in the form of Fowler's solution — in small 
doses even with infants. He says that it seldom failed to put a stop to 
the disease in about a fortnight, and that with proper precautions no ill 
effects were produced. 

367. When the disease is pretty well advanced, and especially when 
the constitution has suffered, if there be neither complication nor fever,, 
great benefit will be derived from tonics ; and of these, perhaps, cin- 
chona has the most advocates. 

Dr. Burton, Mr. Sutliff, Dr. Lettsom, and Dr. Armstrong recommend 
it very highly in combination with tincture of cantharides and paregoric, 
as in the following formula for a child of three years old : — 

R. — Decoct, cort. Peruv. gvj. 

Elixir sudorif. (paregoric) giij. 
Tinct. cantharid. gj. — M. 
Capiat semi-unciam ter in die. 

Dr. Hamilton speaks highly of the Peruvian bark. 

We have the evidence of Dr. Beatty as to the value of Mr. Sutliff's 
compound of bark, paregoric, and tincture of flies; and, on his recom- 
mendation, Dr. Graves was induced to try it, and found it very suc- 
cessful. 1 

Dr. Golding Bird speaks most highly of alum in the second stage, 
after all inflammatory symptoms have subsided and the mucus is tena- 
cious and expectorated with difficulty. He gives from two to six grains 
of alum every four or six hours, to children from one to ten years of 
age. The following is his formula for a child of two or three years : — 

R. — Aluminis gr. xxv. 
Extr. conii gr. xij. 
Syr. rhoeados sjij. 
Aqu£e anethi ^iij. — M. 
Capiat cochl. med. 6ta quaque bora. 

Dr. Davies, in his edition of Underwood, " attaches more value to 
alum than to any other form of tonic or antispasmodic." 

Tannin, in doses of from half a grain to gr. iij, every second, third, 
or fourth hour, has been recommended by some high German autho- 
rities. 

Dr. Durr speaks highly of tannin and benzoin in the latter stages of 
hooping-cough. He gives from two to five centigrammes of each with 
fifty centigrammes of sugar every two hours. 2 

Dr. E. Watson applied Dr. Horace Green's plan of cauterizing the 
glottis and larynx with a solution of nitrate of silver, and in several 
cases with apparent' success. The strength of the solution was gr. xv 
to the ounce, and applied by whalebone tipped with sponge, at first to 
the pharynx only. 

Oxide of zinc has been praised by Guersent and Lombard ; the 

1 Graves's Clinical Med., p. 762. 

2 ProY. Med. and Surg. Journ., Ap. 3, 1850. 



PERTUSSIS. 255 

lobelia inflata by Eberle ; the rhus vernix, garlic, and electricity by 
others ; arsenic by Dr. Ternan and Mr. Simmons ; sulphuret of potash 
by Dr. Bland ; the sesquioxide of iron by Drs. Steymann and Lom- 
bard, &c. y liquor ammoniae by Dr. Peyroton, &c. In fact, there is no 
end to the list of remedies which have been recommended in hooping- 
cough ; and probably my readers may thank me for not extending mine 
further. I think I have included the most important ; and I shall only 
notice, in conclusion, the use of external counter-irritants and change 
of atmosphere. 

That external rubefacients are of use there is no doubt, especially 
when combined with a narcotic, as already mentioned ; but that they 
will cure or cut short the disease I do not believe. Roche's embrocation 
is a popular liniment, or we may order one of compound camphor lini- 
ment and laudanum, two ounces of the former to two drachms of the 
latter. The chest and back should be rubbed alternately morning and 
evening. Dr. Hamilton seems to approve of garlic to the soles of the 
feet ; and a popular use of it is to steep it in brandy and rub the spine. 
The celebrated " pommade d'Autenrieth" is simply tartar-emetic oint- 
ment, which is most strongly recommended by many writers of high 
authority. 

Vaccination has been recommended as a remedy. I am not aware 
of its having been tried in this country ; but Dr. Hess informs me that 
some continental experience is rather favorable to it. 

[I have employed vaccination in several cases, and have every reason 
to be satisfied with the result, having found it to modify both the 
severity and length of the affection.] 

868. Great stress has been laid upon change of air, and no doubt, at 
a certain period, the removal from a town to the country, if the air be 
mild and the weather fine and warm, does promote convalescence ; but, 
on the other hand, much mischief may result from indiscreet changes 
and undue exposure. Dr. Merriman remarks, most judiciously, " I am 
not acquainted with many, if with any, instances in which the force of 
the disease has been abated by change of air. I should not recommend 
it for this purpose; but I have often witnessed its usefulness in short- 
ening the stay of the distemper after its force was abated. I believe 
that change of air is seldom advisable (unless the patient be placed in 
a house particularly close and unventilated) during the active stage of 
hooping-cough ; but when the violence of the complaint is subdued it is 
highly beneficial, particularly if the change be from a cold situation to 
one of a warm temperature, or when the coldness of winter and the 
bleak east winds of March are changed to the more genial warmth of 
spring and the mild western breezes of April and May. But even then 
much discretion is required to regulate the time and mode of exposure 
to the open air, otherwise ill consequences are likely to ensue." 1 

Dr. Mackintosh remarked, in a severe epidemic, that all the children 
that were removed for change of air had the disease the longest. 

Dr. Beatty made it a rule to confine his patients to their bedroom 
until the cure was completed ; and Dr. Graves seems to approve of his 
plan. Of the two extremes, doubtless it is the best. 

1 Underwood on Diseases of Children, p. 428. Note. 



256 PERTUSSIS. 

During the catarrhal stage, I have always confined the child to the 
house, and during the commencement of the second stage, unless the 
weather was very mild and dry. After this the child will benefit by an 
occasional walk or drive on fine days and during the warm parts of the 
day ; then, when the cough is fairly on the decline, a change from town 
to the country will accelerate the convalescence. 

Great care should be taken that the rooms in which the child passes 
the day and night should be well ventilated and of a comfortable tem- 
perature. This will be particularly necessary in very severe cases, or 
in winter, because the child must then be confined altogether to the 
house. 

The diet at fir,st should be rather restricted : all stimulating food 
should be withheld, and cooling drinks allowed freely. As the second 
stage advances, the diet must be improved, broth or meat allowed 
according to the age of the child and its condition, and perhaps a little 
wine and water. 

369. Treatment of the Complications. — A considerable deviation from, 
or addition to, the treatment already indicated, will be necessary when 
either of the complications I have described, exist. It will not, how- 
ever, be necessary to enter at length into the subject at present, as the 
reader will find all the details in the chapter on bronchitis, pneumonia, 
convulsions, &c. I shall mention so much of it only as will indicate 
the line to be pursued and the modifications required. 

Whenever we detect the evidences of bronchial or pneumonic inflam- 
mation, it will be necessary, notwithstanding the hooping-cough, to 
adopt prompt and energetic treatment. Unless the child be greatly 
exhausted, we must have recourse to bloodletting, either by a free use of 
the lancet or by an equivalent number of leeches, arresting the bleeding 
when the leeches fall off, or by cupping, if the child be old enough. Dr. 
Mackintosh states that he found great benefit from leeches applied over 
the larynx. After relief from bleeding, and as scjpn as the fever has 
somewhat subsided, a blister may be applied to the chest ; and here let 
me repeat that I have found a succession of small blisters much more 
effectual with children than one large one, and also that we must be 
cautious not to leave them on too long, especially with infants, as the 
surface, when much inflamed, is apt to ulcerate. Two or three hours 
are sufficient for children up to five or six years of age ; and although 
there may be no vesication when we remove it, it will take place after- 
wards. Let me add, that it is better not to cut the blister, unless its 
prominence makes the child uncomfortable, and that the best dressing, 
if the surface be not broken, is French wadding or cotton wool. 

Internally, we must increase the quantity of ipecacuanha wine in case 
of bronchitis ; but in pneumonia we must have recourse to tartar emetic 
in small doses, from its well-known power over that disease. Either 
remedy may be added to the expectorant mixtures formerly advised, 
and continued, so as to keep up a slight nausea, unless the bowels 
become affected. In such a case, we may try small doses of calomel 
and Dover's powder, or some other antiphlogistic remedy. If the child 
be much weakened, the addition of ammonia to the expectorant mixture 
or its alternation with it, will be advisable. I have also seen great 



PERTUSSIS. 257 

benefit from spirits of turpentine given alternately with the ipecacuanha 
or tartar emetic. 

The bowels must be carefully regulated. Brisk purgation rather 
does mischief than good, but a gentle purgative now and then may be 
necessary. If there be diarrhoea, chalk mixture with aromatic confec- 
tion and a very small quantity of laudanum, will be of use. 

370. If the child be attentively watched, the second complication, 
disordered bowels and remittent fever, may, in most cases, be prevented. 
At each visit an accurate account of the state of the stomach and bowels 
should be obtained, and the treatment judiciously adapted to avoid 
these inconveniences. If the bowels be constipated, a brisk purgative 
may be given, followed by an enema, if the medicine be ineffectual. 

When the congestion about the head is considerable, it is often 
accompanied by obstinate constipation, which does not yield until the 
cerebral condition has been relieved by bleeding. 

If the bowels be not constipated, but the discharges are unhealthy 
in colour or smell, which is by no means uncommon, mild laxatives, 
with small doses of hydr. c. creta or calomel, will probably excite bene- 
ficial action upon the mucous membrane, and restore the natural secre- 
tions. 

When diarrhoea is present and considerable, we must have recourse 
to some astringent medicine — chalk mixture, compound powder of chalk, 
powder of chalk and opium, &c. I generally order the following simple 
mixture for a child of a year old : — 

U. — Mist, cretse gj. 

Confect. arom. gr. v. 

Syr. zingib. gij. 

Tincturse opii gtt. ij. — M. 
Cap. cochl. i. parv. ter quaterve in die. 

Increasing the quantity of laudanum if the child be older, and adding a 
little tincture of kino or catechu if the purging be obstinate. 

Gentle frictions of the abdomen with compound camphor liniment 
and laudanum, or fomentations, are very useful. 

A small starch enema, with a few drops of laudanum, will often arrest 
the discharge after other measures have failed. I have also derived 
great benefit from hydrocyanic acid in this complication ; it decidedly 
diminished the irritability of the bowels at the same time that it acted 
beneficially upon the cough. 

The diet must be carefully guarded, nutritious but not too stimu- 
lating, and rather of solid food than fluid, if the child be old enough. 

For the management of remittent fever I must refer to the chapter on 
that subject, as the only result of its being a complication will depend 
upon the constitution of the child. 

371. With regard to the treatment of convulsions occurring in hoop- 
ing-cough, the first thing is to remove the ordinary exciting causes, if 
they exist; the gums should be freely divided, the bowels freed, and a 
warm bath administered. Notwithstanding, the convulsions will con- 
stantly recur, and in these cases there are two plans strongly recom- 
mended by Dr. Johnson : " One is a total alteration of the child's diet, 

17 



258 PERTUSSIS. 

and the other is change of air. When the child affected is at the breast, de- 
fectiveness in quantity or quality will usually be detected in the nurse's 
milk. Often it will be found that she has menstruated, or, as sometimes 
happens, without the discharge actuall} 7 occurring, she has experienced 
sensations similar to those which attend the accession of the catamenia. 
In such cases the milk almost uniformly disagrees, and hence it is a good 
rule, whenever the convulsive attacks withstand ordinary treatment, to 
inquire into the state of the nurse, and, if there be any ground of sus- 
picion, to have a young and healthy one procured. Change of air often 
in the most remarkable manner puts a stop to the recurrence of convul- 
sions, and will be found particularly beneficial in those cases of spasm 
of the glottis to which we have alluded." 

More active treatment than this will, of course, be necessary; leeches 
to the forehead or behind the ears, cold lotions, and probably a blister 
to the nape of the neck, with a purgative, should immediately follow an 
attack of convulsions. If we succeed in mitigating their severity, it 
will be well to establish a permanent drain by a seton of two or three 
threads in the arm. as heretofore recommended. 

But in the majority of cases, all our treatment will be in vain, unless 
we can contrive to lessen the frequency and violence of the cough; the 
reiterated arrest of the circulation will shortly reproduce the convulsion. 
For this purpose T have found the hydrocyanic acid of great value; if 
anything will check the cough, it will he either that or the belladonna. 
I should think it probable that the same effects would follow the chlo- 
roform or ether, but as yet I have had no opportunity of trying either. 
I am not prepared to say whether the convulsion ought to prohibit their 
use, but 1 rather think not. 

372. These observations will apply as well to hydrocephalus^ with 
the addition that, as the disease is more hopeless and more serious, our 
treatment must be more active, limited only by the state of the child's 
constitution, and by the recollection that, in the event of recovery from 
the complication, it has still a, long and exhausting disorder to encounter. 

In addition to the leeching, cold applications, blisters, and purgatives, 
we must give a fair trial to mercury in whatever mode it is heat borne 
by the child; and if we are successful in controlling the secondary affec- 
tion, a more liberal use of tonics, and a more generous diet, will be ne- 
cessary at an earlier period than usual. 

378. When the symptoms of cerebral congestion or apoplexy make 
their appearance, no time is to be lost in abstracting a. sufficient quan- 
tity of blood, and the effect of this first bloodletting will guide us as to 
the necessity for its repetition. If the stupor diminishes, the intelli- 
gence returns, and the child appears more conscious of what is passing, 
we may either repeat the bleeding after an interval, or have recourse to 
counter-irritation, cold lotions, and purgatives. 

If there be no return of sensibility, or diminution of the stupor or 
Coma, the case is one of apoplexy from effusion, and with so powerful 
an exciting cause continuing as hooping-cough, it is not likely that any 
treatment will he of use. We may, as a matter of duty, try the reme- 
dies I have recommended for apoplexy, but it, is most likely that they 
will altogether fail. 



croup. 259 



CHAPTER IV. 

CROUP. — CYNANCHE TRACHEALIS. 

874. The disease which is the subject of the present chapter consists, 
essentially, in inflammation of the larynx and trachea primarily, but 
which may occupy a greater extent of the respiratory organs; accom- 
panied by a peculiar pellicular secretion, with a certain amount of spas- 
modic action, modifying the respiratory and vocal functions. 

By the ancients it seems to have been confounded with other diseases 
of the air-passages. According to Cheyne, Michaelis, &c, Baillou, of 
Paris, in 1576, was the first to indicate the anatomical characters of 
croup. Etmiiller described a disease strongly resembling it, and after 
him Molloi, 1743; Malouin, 1746; Ghisi of Cremona, in 1747, who 
called it angina strepitosa; Starz, in 1749 (morbus strangulatorius) ; 
Middleton, 1752; Bergius, 1755; Rudberg, 1755; Berghen, 1759; 
Wahlbom, 1761; and Wilcke, 1764. It was first noticed by its present 
name by Dr. Blair, of Cupar Angus, in 1718. In 1765, Dr. Home, of 
Edinburgh, published his essay, in which the disease was first accurately 
described, and from original observations. He was succeeded by several 
writers, among whom I may mention Eller, 1766; Engstroem, 1767; 
Rosen, 1771; Rush, 1769; Bard, 1771 ; Callisen, 1776; Buchan, 1776; 
Turnbull, 1776; Mahon, 1777; Middleton, 1780. Since this period 
numerous monographs of greater value have appeared, by Jurine, Albers, 
Vieussieux, Valentin, Cheyne, Blaud, Bretonneau, Guersent, Trousseau, 
Desruelles, &c. ; and it has formed a very important chapter in the sys- 
tematic works on diseases of children, besides being more or less de- 
scribed by writers on diseases of the respiratory organs. 

It has been described under various names, but I prefer the ordinary 
name "croup," as being generally intelligible, and as involving no pa- 
thological opinion. 

375. It is one of the most alarming and fatal diseases to which chil- 
dren are liable; sudden in its attack, alarming in its symptoms, and 
rapid in its results, it sweeps over a family, leaving behind it distress 
a,nd desolation. 

Generally speaking, it attacks children between the ages of one and 
twelve years, and most frequently those under five years. Marley men- 
tions having seen it in an infant at the breast; 1 Hamilton in one of six 
qr eight mouths; 2 Cheyne in one of three months; 3 Bouchut in one of 

1 Diseases of Children, p. 13^. 2 Disc; 863 of Infants, p. 142. 

3 Pathology of the Larynx and Bronchia, p. 15. 



260 croup. 

eight days old. 1 M. Andral gives the following table of ages in 332 
cases. It occurred 



During the 1 st month in 


1 case. 


3d » " 


1 " 


5th " " 


1 " 


From 5 to 12 months " 


18 cases. 


" 1 to 2 years " 


61 " 


" 2 to 3 " " 


45 " 


« 3t0 4 « 


54 " 


" 4 to 5 " " 


42 " 


" 5 to 6 " " 


29 " 


" 6 to 7 " 


29 " 


" 7 to 8 " 


3 " 


" 8 to 11 " 


6 " 


" 11 to 15 " 


7 " 


" 15 to 30 " " 


13 " 


« 30 to 50 " 


10 " 


« 50 to 70 " 


12 " 



In thirty cases observed by M. Trousseau, thirteen were from eleven 
months to three years of age, eleven from three to five years, and six 
from five to twenty-six. 2 

" In Philadelphia, during the ten years preceding 1845, 475 deaths 
are reported from croup, in infants between two and five years; 238 in 
those between one and two years; 319 in those under one year; 112 
in those between five and ten years; and six in children over ten years." 3 

MM. Rilliet and Barthez state that primary croup is most frequent 
between the ages of two and seven years; and of eleven cases of se- 
condary croup, six were from two to five years, and five beyond that age. 4 

Dr. Vauthier states that, of thirty-seven cases, twenty-five occurred 
at or under two years of age. 5 

Mr. Wilde observes, in his Report upon the Irish Census of 1841 : 
"This fourth most fatal epidemic affection carried off 42,705, in the pro- 
portion of 100 males, to 82.89 females. The registries of this disease 
afford returns of death up to the adult age, even so high as 30, and 
one at 40." From the fifth to the tenth year, the deaths amounted to 
1316 males, and 1292 females. " Compared with other infantile dis- 
eases, the deaths during the first year are 100 to 48.29 of measles ; 
100 to 6.82 of scarlatina ; 100 to 92.62 of hooping-cough; 100 to 4.98 
of thrush; and 100 to 60.1 of pemphigus." 6 

From these details, it will be seen that it is not altogether confined to 
infants or children, but that adults, and even old people, are occasionally 
attacked, upon which M. Louis has published a valuable paper. 7 

There is another fact concerning croup, in direct opposition to what 
occurs in hooping-cough, alluded to in Mr. Wilde's report, viz : that it 
is more frequent among males than females, and which is confirmed by 
general experience. Of M. Trousseau's thirty cases, twenty-two were 
males and eight females; and of M. Jansecowich's twenty-five cases, 
there were seventeen boys and five girls. 

1 Mai. des Nouv. Ne"s, p. 265. z Barrier, Mai. de FEnfance, vol. i. p. 414-5. 

3 Condie, Diseases of Children, p. 332. 4 Mai. des Enfans, vol. i. p. 351. 

6 Arch. Ge"n. de MeU, May, 1848, p. 10. « Wilde's Report, p. 16. 

7 Recherches Anat. Path., p. 203. Sur le Croup cousidere chez l'Adulte. 



croup. 261 

376. Different classifications have been made of the varieties of croup, 
according to the predominance of peculiar symptoms. Thus we have the 
catarrhal, the spasmodic, and the inflammatory croup of some authors ; 
the acute and spurious of Ferrier ; the three varieties of M. Blaud, 
dependent mainly on the intensity of the attack ; the three species of 
M. Porter, 1 the spasmodic, the inflammatory, and a third, in which the 
lining membrane has become thickened and altered, so as to spoil the 
appearance of the organ and interfere with its functions. The com- 
mencement is insidious, its progress slow, and its termination fatal. 

Dr. Stokes divides croup into primary and secondary ; the latter being 
an extension of the disease from the neighboring parts, or a complica- 
tion with other diseases. 2 

It appears to me, however, that most of these distinctions are only 
differences in degree, or in the predominances of certain characters over 
others; the only invariable one, if the disease be allowed to run on, 
being the inflammation and the false membrane. Experiments made by 
Schwilgue, Schmidt, Chaussier, and others, have proved that the same 
causes, applied to animals of the same class, have given rise to each 
variety, according to the peculiar constitution and age of the animal. 

The plan I propose, therefore, is to describe inflammatory or primary 
croup, as it ordinarily occurs ; then to speak of the modifications arising 
from the predominance of some one characteristic, as the spasm ; of its 
complications ; and lastly, of the secondary form of the disease, either 
owing to its extension, or to its complicating other diseases. 

377. Symptoms. — The course of the disease has been divided into 
four stages by Golis — the invading or catarrhal, the inflammatory, the 
albuminous, and the suffocative stage. Dr. Cheyne makes two stages — 
the incomplete or inflammatory, and the complete or purulent ; Dr. 
Dewees into three — the forming, the completely formed, and the con- 
gestive stage ; M. Guibert into three — the stage of irritation, that of 
albuminous secretion, and that of suffocation. 

I prefer adopting that of Dr. Copland, 3 nearly the same as Dr. Stokes's, 
and shall speak, first, of the precursory stage ; second, of the stage of 
development ; and third, of the stage of collapse, or threatened suffo- 
cation. 

I. The Precursory Stage. — As a general rule, some catarrhal symp- 
toms precede an attack of croup. The child is cross and feverish, the 
skin hot, the pulse quick, the thirst increased ; there may be sneezing, 
lachrymation, and cough. There is always a change in the voice, a 
degree of hoarseness, to which, as the surest sign of an approaching 
attack of croup, Dewees and others attach great importance. It is not, 
however, like the subsequent hoarseness, but rather an unusual huski- 
ness, as though the throat needed clearing. 

If we examine the pharynx, we shall discover no trace of disease ; 
the tongue is generally loaded but moist; there is evident uneasiness in 

1 Surgical Pathology of the Larynx and Trachea, p. 29. 

2 Diseases of the Chest, p. 205. 

3 Let me here, once for all, acknowledge my obligations to the learned and accurate 
work of Dr. Copland ; to it and to the works of MM. Barrier, Rilliet and Barthez, I am 
more indebted than to any others. My deep sense of their value must be my apology for 
the free use I have made of them. 



262 croup. 

the windpipe, and the cough is short and generally dry. The chest is 
resonant, and it is rarely that we can detect any morbid sounds with 
the stethoscope, and then only some slight bronchial rales. The rapid- 
ity of breathing will be in accordance with the amount of the fever, 
quickness of pulse, &c. In some cases it is greatly hurried, in others 
pretty quiet. 

Vieussieux lays great stress upon the catarrhal symptoms and changes 
in the voice ; but although the latter is very characteristic when present, 
many cases occur in which there is neither the premonitory catarrh nor 
hoarseness, but where the disease first appears fully formed. 

The duration of the precursory stage is very uncertain, varying from 
a few hours to a day or two ; as a general rule, it does not extend beyond 
eighteen or twenty-four hours. 

378. ii. Stage of Development. — After the symptoms I have men- 
tioned have characterized the first stage, increasing towards evening, 
or without any warning in cases where the first stage is absent, the child 
is suddenly awoke out of sleep by a sensation of suffocation, with a hoarse 
ringing cough, hurried and hissing respiration, and a rough hoarse voice, 
with great alarm, agitation, and distress. 

Ferrier, 1 Cheyne, 2 and indeed most writers, have noticed, as a pecu- 
liarity, the first occurrence of the croupy cough at night, without giving 
any explanation of it. It seems probable that it may be another exam- 
ple of the disposition there is in nervous or convulsive attacks to occur 
in the night. After mentioning the setting in of this stage with "in- 
crease of fever, anxiety, and distress, and by indications of mechanical 
obstruction in the larynx itself" Dr. Stokes remarks : "Indeed, one of 
the most remarkable circumstances connected with the disease is the 
rapidity with which this latter symptom shall occur, a fact strongly 
confirmatory of the opinion that the mere effusion of lymph is not the 
principal cause of the obstruction, but that it is owing to the inflamma- 
tory spasm of the part." 3 I have no doubt that thus early the dyspnoea 
and peculiarity of the cough are chiefly owing to spasm of the larynx, 
and, like similar nervous affections, they are peculiarly apt to occur in 
the night. 

" The child's illness," says Dr. Cheyne, " does not prevent him from 
going to sleep at the usual time ; but he awakes with an unusual cough, 
suffocative, acute, and ringing. His breathing is difficult ; often the 
inspirations, particularly those which follow the cough, are crowing. 
His face is swelled and flushed, and his eye is watery and bloodshot, 
and he seems in danger of suffocation ; his skin is hot, and he has some 
thirst. He labors in breathing, and still the difficult and perhaps crow- 
ing inspiration continues, and the distinctive cough. He tries to relieve 
himself by sitting up or coming out of bed. No change of position 
gives him relief. Generally, his sufferings are thus protracted until 
morning, when, perhaps, there is a slight remission." 4 

The cough, then, with the rough breathing (bruit serratique) and the 

1 Med. Histories and Reflexions, vol. iii. p. 134. 
a Pathology of the Larynx and Bronchia, p. 16. 

3 Diseases of the Chest, p. 208. 

4 Pathology of the Larynx and Bronchia, p. 15. 



croup. 263 

hoarse voice, are the distinctive characteristics of this stage. The sound 
of the cough is so peculiar that, once heard, it is never forgotten. It 
resembles slightly the crowing of a cock or the bark of a dog, but still 
more succussions of air through a brazen tube ; it has a ringing metallic 
tone in it. The breathing is evidently changed by the air being forced 
through a narrower orifice than usual, and the voice has a rough hoarse- 
ness even when quiet, but very marked when the child is crying. 

The paroxysms of coughing become more frequent and spasmodic, 
during which the inspiration is almost suspended and the heart's action 
accelerated. The difficulty of respiration and the consequent efforts 
on the part of the child are very great ; the countenance is flushed, 
sometimes almost livid, and covered with sweat; the hands are clinched, 
the arms thrown about, all covering rejected, and whatever might im- 
pede the access of air is hastily removed. The body is sometimes erect, 
sometimes recumbent, and occasionally with the head rigidly bent back- 
wards. 1 The eyes project, and are injected and suffused. The carotid 
arteries beat strongly, the pulse is quick and hard, the skin burning, 
and the thirst great. The little patient refers the seat of distress to 
the larynx, to which the hand is frequently carried, as if to remove 
some obstruction, and where, as Dr. Ferrier has remarked, a degree of 
tumefaction is sometimes observed. As yet, there is scarcely any 
expectoration. 

379. In a simple case of croup, the stethoscopic signs are chiefly of 
a negative character; the chest sounds clear on percussion; the respi- 
ratory murmur is hurried and unequal ; the croupy sound and sibilant 
breathing are heard over the larynx. But occasionally the information 
is more positive. Dr. Stokes observes : " The active physical signs 
referable to the lungs, which I have had an opportunity of detecting, 
have been as follows: First, a diffuse sonorous rale, not so intense as 
to extinguish the vesicular murmur ; secondly, the same rale, but with 
more intensity, indicative of disease in the more minute tubes; thirdly, 
a combination of the sonorous and mucous rales, causing a loud sound, 
and a feeling of vibration when the hand is applied to the chest ; 
fourthly, the crepitating rale of pneumonia in one or both lungs ; in 
some cases, with distinct dulness of sound on percussion. I have not 
heard the bronchial respiration of hepatization, or the frottement of 
pleurisy; but there can be no doubt that if these conditions existed 
before the laryngeal disease had obtained its maximum, these signs 
would be distinctly audible." 2 Several of these signs are referable to 
the complication of croup, as we shall see by and by. Dr. Williams 
notices a "weak respiratory murmur in the chest, which yet sounds well 
on percussion," and "a concave state of the intercostal spaces at each 
inspiration." He further states that ' v the sonorous inspiration of croup 
is audible through the stethoscope applied to the throat or upper part 
of the chest before it can be heard by the ear unapplied." 3 In addition, 

1 This peculiar symptom is observed in several different diseases, and, among others, 
spinal arachnitis, pleuritis, pericarditis, &c; and I have in vain striven to make out its 
exact import. In croup, however, it appears to be a mechanical arrangement to facilitate 
the passage of air by straightening the primary air- tubes. 

2 Diseases of the Chest, p. 214. 3 Diseases of the Chest, p. 84. 



264 croup. 

M. Bartliez remarks that at a certain period of the disease, when the 
stethoscope is applied to the larynx, we may perceive a peculiar vibra- 
tion, as of something flapping, which always indicates the existence of 
loose false membrane ; and if this be confined to the larynx, it is so 
far a favorable sign that it announces the concretions to be slightly 
adherent, and capable of being removed by expectoration. If, on the 
other hand, this vibration be prolonged into the trachea and bronchial 
tubes, it is unfavorable, from the evidence it affords of the great extent 
of the disease. 1 

Thus, the physical examination of the chest may yield either positive 
or negative results of great practical value in' the treatment of the dis- 
ease, and at each visit we should make ourselves acquainted with its 
exact condition. 

380. The symptoms already mentioned, the cough, dyspnoea, and 
hoarseness, first appear and afterwards increase during the evening and 
night, along with the fever, and diminish in the morning, when we find 
the fever less, the cough not so frequent, perhaps less characteristic, 
and the inspiration less labored. This intermission may continue during 
the greater part of the day; but the exacerbation reappears towards 
evening, probably after a sleep, with greater severity than before. The 
cough, dyspnoea, anxiet} r , and fever are increased ; the hand is con- 
stantly applied to the throat to remove the obstruction ; and the larynx, 
when pressed, is sometimes painful. The countenance is swollen, puffy, 
and flushed or livid; the eyes prominent and suffused ; the expression 
that of agony. The pulse is quick, hard, and small ; the skin is hot 
and dry, except the face and head, which generally perspire profusely 
during the fits of coughing. The child is restless, and constantly 
changing its position in the hope of obtaining relief. 

The respiration increases in difficulty, and the voice in hoarseness ; 
the cough is sudden, convulsive, and ringing, terminating often in a 
crowing inspiration. There is little or no expectoration. 

381. Arrived at this period, the progress of the disease becomes very 
rapid, and its advance is marked at every step by an aggravation of the 
symptoms., The remissions are less perceptible, the cough more diffi- 
cult, suppressed, and strangulating; suffocation more imminent; and the 
paroxysms are occasionally followed by vomiting, and the expulsion of 
a glairy mucus, sometimes, but rarely, mixed with flocculent or mem- 
branous shreds, which affords temporary relief. The croupal respira- 
tion is permanent and increases, and if the lungs be unaffected, the ribs 
are drawn somewhat inwards, and towards the mesial line (as in atelec- 
tasis) instead of being protruded by the distended lungs ; the voice be- 
comes broken, whispering, and suppressed, partly from the pain it ex- 
cites, and partly from its bringing on the cough. Deglutition is occa- 
sionally difficult, and gives rise to fits of coughing and strangulation. 

The bowels are generally constipated, and the urine sometimes clear, 
pale, and abundant ; in other cases scanty, thick, and high colored, and 
occasionally whitish and turbid, particularly towards the close of the 
second stage. 2 

1 Archives Gen. de M6d., July, 1838. 2 Valentin, sur le Croup, p. 219. 



croup. 265 

382. It is during this second stage or period of development that 
the pathological peculiarity of the disease, the secretion of false mem- 
brane, occurs, but at what period, or by what symptoms it is indicated, 
it is difficult to determine. 

M. Blaud states that he has found the larynx and trachea lined with 
false membrane, in cases whose whole course did not occupy more than 
twenty hours, whilst in others several days elapsed before it was formed. 

The evidence derived from auscultation on this point is not always 
certain or precise. The vibration spoken of by M. Barthez is, I should 
think, pretty conclusive, but it is by no means common, and it is not 
easy to say whether the sonorous laryngeal inspiration is at the moment 
we examine, due to inflammatory spasm, to the mechanical obstruction 
of the false membranes, or to both combined. M. Trousseau states 
that when the cough, having been clear, loud, and ringing, becomes less 
frequent, and at length almost without sound and suffocating, we may 
be certain that exudation has taken place. 1 

Occasionally the expectoration will throw some light upon the matter. 
Early in the disease the child expectorates nothing, or a little frothy 
mucus; but in some more advanced cases shreds of lymph are thrown 
off, and on this account we should never omit to examine the sputa 
carefully. Dr. Hegewisch 2 recommends their being put into hot water 
to render them more apparent : they should always be placed in water 
for examination. No doubt this is a symptom of considerable impor- 
tance, but, as Rilliet and Barthez have observed, it is far from being 
frequent, and rarely occurs before an advanced period of the disease, 
perhaps the day before death. In one of their cases it occurred on the 
fourth day. 

It does not appear, then, that we can lay down any symptom which 
will prove that lymphatic exudation has actually occurred, nor have we 
any evidence to show that this occurs at any regular period of the 
attack. It cannot be doubted that it does take place during the second 
stage, but the exact time seems to vary in different cases. 

383. in. Period of Collapse. — This stage may set in from the third 
to the seventh day after the invasion, according to the intensity of the 
inflammation or the peculiar constitution of the child. It is charac- 
terized by the absence of any remission, by the aggravation of all the 
symptoms, especially the pulse and respiration, which are greatly accel- 
erated, and with diminished power. The pulse is not only quick and 
weak, but often unequal and intermitting ; the cough is less frequent, 
less sonorous, suppressed, and suffocative. The voice is low, whisper- 
ing, or perhaps entirely abolished ; the speech quipk, imperfect, or lost. 
The respiration is extremely difficult, and accompanied with a loud hiss- 
ing noise. All the muscles of inspiration are called into powerful ac- 
tion ; thus the alge nasi, the muscles of the neck, chest, diaphragm, and 
abdomen, all act with great force, and the movements of the larynx 
are extensive and incessant. The head is constantly thrown back, the 
forehead is covered with cold perspiration, the eyes are sunken and dull, 
and the complexion is livid, or of a leaden color. The surface gene- 

1 Journal de Connois. Med. Chir., 1884, p. 3. 2 Rust's Magazine, vol. xxxii. p. 2. 



266 croup. 

rally is pallid, and the veins are very visible, especially those of the 
neck, which seem unusually distended. The tongue is dark-colored and 
loaded, the lips sometimes purple, in other cases of a livid paleness ; the 
thirst is often intense, but can only be gratified at the risk of suffoca- 
tion. The bowels are rather confined ; the motions are dark and fetid. 

There is generally some little expectoration, and it may be that, by 
great efforts, some shreds of the lymph mayjbe thrown off from the 
larynx, with manifest relief for the time, but followed by a return of 
the distressing suffocation. 

The whole expression of the child's face, figure, and posture, is one 
of unmitigated distress, of the agony of oppressed breathing, of the 
horrible dread of suffocation. It turns on every side for relief and finds 
none ; it changes its position, lying down or sitting up, restless and 
anxious as those who strive for the breath of life, and despairing as 
those whose efforts are in vain. Awake or asleep, the distress con- 
tinues ; it finds no relief in the arms of its mother, no comfort in her 
caresses. 

From this condition the child rarely recovers; there may be occa- 
sional remissions, as I have mentioned, after the expectoration of mucus 
and lymph, but this is only temporary, and as the disease extends itself 
downwards, along the bronchial tubes, all chance is excluded. The 
local and general distress increases ; the efforts at respiration partake 
of a convulsive character ; the passage of air through the larynx be- 
comes more and more difficult; and after a short time, seldom above 
twenty hours, death terminates the painful scene. 

The child may either expire with signs of convulsive suffocation, or 
it may fall into a state of stupor from exhaustion of the vital powers, 
and die lethargic. The younger the child, the more liable it is to have 
the disease terminate by convulsions. 

Occasionally, the disease terminates more suddenly than I have de- 
scribed ; the child has appeared to be instantly suffocated just when 
the symptoms had become somewhat more favorable ; and, in some 
of these cases it has been owing to the partial detachment of the 
false membrane, and the formation of a valve whose closure proved 
fatal. 

384. Such is the course of the severe form of croup, when uncom- 
plicated and unchecked by treatment. It may, however, run a different 
and- less fatal course. The fever may be slight, and the laryngeal 
affection much milder. Still there will be the sibilant and impeded 
respiration, the croupy cough, and the hoarseness, never to be mis- 
taken when once they have been heard. These will be troublesome 
during the night, and perhaps there may be more or less complete 
remission during the day. No matter how slight the attack may be, 
the most vigilant care is requisite, as the disease very often acquires 
great intensity in a very sudden manner, and a very few hours lost can 
never be regained. 

Or, if the treatment be early, active, and judicious, the disease may 
be checked in either the first or second stages, and we shall then find 
that the character of the cough will be changed ; it becomes softer and 
more moist ; the respiration, although for a time rough, is much easier 



croup. 267 

and less hurried, and the voice acquires some tone ; the case assumes 
the aspect of common catarrh, with hoarseness. I have seen this change 
take place in my own children in two hours, when the disease was 
attacked in the very commencement. In more severe cases, the fever, 
with evening exacerbations, may continue for some time after the voice, 
cough, and breathing have lost all croupy character, as in a case at pre- 
sent under my care. 

We must never forget the great liability of the disease to relapse, 
nor cease our watchful care until the patient has perfectly recovered. 
It is also very apt to recur in the same individual. According to 
Jurine and Albers, it has been known to recur seven and nine times. I 
have seen it occur two, three, or four times. Nor can we be sure that 
every attack will be equally mild ; a child may recover from two or 
three attacks, and be destroyed by the next. Much of the chance of 
recovery depends upon our seeing the disease at its commencement, for 
even the milder cases, if neglected, may assume greater intensity, and 
destroy the patient. 

385. The duration of the disease depends partly upon the severity 
of the inflammation, and partly upon the vital energy of the child. 
It may prove fatal in twenty-four or thirty-six hours, as Dr. Hamilton 
mentions, or it may last nine or ten days. Dr. Cheyne states that it 
generally proves fatal on the third, fourth, or fifth day. 

Probably from three to six days will be found to include the greater 
number of cases. 

386. Pathology. — The morbid phenomena exhibited on dissection, by 
the structures chiefly occupied by this disease, are the following: — 

I. The mucous membranes of the larynx and trachea, in the majority 
of cases, show evidences of inflammation ; they are of a bright red, vas- 
cular, and thickened, so that they can be peeled off easily. Occasionally 
the redness is partial, with patches of ecchymosis around the follicular 
orifices ; and in some rare cases, as has been noticed b}^ Albers and Ju- 
rine, Rilliet, and Barthez, the mucous membrane is pale, and apparently 
perfectly healthy, underneath the false membrane. This Albers ex- 
plains by supposing that the inflammation subsides after the peculiar 
secretion is accomplished. 

The orifices of the mucous follicles are often in a state of dilatation. 
Jurine remarks that they give the mucous membranes a dotted ap- 
pearance, and that they are larger on the membranous portion .of the 
trachea, in the direction of its longitudinal fibres, and in their in- 
tervals. 

387. II. But the characteristic morbid appearance is the false mem- 
brane which lines the air-passages, lying upon the mucous membrane. 
We find a layer of lymph of considerable consistence, of varying 
thickness, and of a whitish or yellowish color, lining the larynx and 
trachea, and sometimes extending into the bronchi. This extension 
to the bronchial tubes occurred in forty-two cases of 120, according 
to M. Guersent, or in about one-third. In some cases it is of small 
extent, resembling grains or patches, between which we see the 
mucous membrane, and occupying different parts of the larynx and 



268 croup. 

trachea ; in others it forms demi-cylinders, or more rarely, entire 
cylinders, or tubes of different length — casts, in fact, of the tubes in 
which it is moulded. It is thinner and more fragile in the larynx 
than in the trachea, and its consistency is least in the bronchial tubes. 
The less the consistence, the greater the probability of its being ex- 
pectorated. 

The free surface of the false membrane is generally smooth, and 
often covered by a layer of muco-puriform matter. The other surface 
adheres more or less strongly to the mucous membrane. In some cases 
it is partially separated by puriform matter ; in others an attempt to 
remove the false membrane brings away the mucous coat. When the 
secretion is extensive and general, it is generally less adherent ; and 
when removed, the surface, which had been in contact with the mucous 
membrane is generally smooth, and of a whitish yellow color, with 
longitudinal strise, owing, probably, to the impression of the muscular 
fibres of the trachea. 

In this adherent surface, also, we may sometimes see a number 
of small red points, which, according to M. Hache, correspond to 
the little ecchymoses of the mucous membrane which I have already 
noticed ; and it has been doubted whether this may not be the com- 
mencement of organization in the false membrane. 1 Soemmering, 
Royer, Collard, Guersent, Blache, and others, believe in the possibility, 
and have discovered vascular striae which penetrate the substance. 
Portal, Valentin, and others, have denied the development of vessels. 
Rilliet and Barthez, without deciding positively, admit the possibility, 
but very sensibly remark, that such cases must be extremely rare on 
account of the rapidity of theVlisease. 

As to the chemical properties of the false membrane, I cannot do 
better than quote the following passages from M. Bretonneau's valuable 
work: "I have endeavored," he observes, "by means of different 
chemical reagents, to establish the differential characters of the croupal 
concretions, the albuminous concretions which are the consequence of 
inflammation of the serous membranes, and the fibrin of the blood, and 
I have not been able to discover any." " Sulphuric, nitric, and hydro- 
chloric acids coagulate all ; acetic acid, liquid ammonia, and alkaline 
solutions, dissolve all, and convert them into a diffluent and transparent 
mucus, exactly at the same temperature, and in the same vessel." 2 

It consists, therefore, of albumen ; and, according to Lelut, it is the 
mucus, enriched with fibrin, in consequence of the inflamed condition of 
the part. Dr. Hosack attributes the membrane to the rapid passage 
of the air. 

Dr. Seitz has recorded a microscopic examination of this membrane ; 
it was about half a line thick, and of a slight consistence ; it was seen 
to be composed almost entirely of pus globules, mixed with inflammation 
corpuscles, and a species of cell double the size of the pus globule, but 
otherwise similar to it. 3 

Instead of this plastic lymph, we occasionally find the air-passages in- 

1 Mai. des Enfans, vol. i. p. 319. 2 Traite de la Diphtherite, p 293. 

8 Ranking' s Abstract, vol. iv. p. 334. 



croup. 269 

flamed, and to a greater or less extent lined with a layer of viscid puri- 
form or muco-puriform matter, offering, of course, an impediment to 
respiration, but more easily expectorated. 1 

388. It may be as well to notice here certain other morbid conditions, 
although they result from the complications of croup, which I shall 
notice by and by. 

The pharynx occasionally participates in plastic exudation, and on 
examination we find it either disposed in patches, or continuous and 
extending into the larynx. In almost all cases the oesophagus ia 
healthy ; in two cases related by Bretonneau, however, the false mem- 
brane lined the whole extent of the tube to a little beyond the cardiac 
orifice of the stomach. In one case, by Ferrand, it extended to the 
commencement of the oesophagus ; and in another, reported by M. 
Lespine, it occupied the inferior third. 

It is rare to find any morbid appearances in the stomach or bowels. 
Rilliet andBarthez met with minute ecchymoses of the mucous membrane 
of the stomach, and a considerable development of the isolated follicles 
of the small intestines, but nothing more. 

The bronchial tubes are often found inflamed, even when there are no 
false membranes ; in some cases the mucous membrane is simply vas- 
cular ; in others red and softened. Moreover, they contain a quantity 
of mucous or puriform fluid. 

In a large proportion of cases — five-sixths, according to Rilliet and 
Barthez — lobular pneumonia exists, and occasionally it is general and 
and extensive ; nor does it depend upon the extension of false membranes 
to the bronchi, for it is present in many instances when they are absent. 

An emphysematous condition of the lungs exists in a large proportion 
of cases in consequence of the asphyxia ; it is generally vesicular, in 
children. 

Dr. Cheyne mentions that serous effusion and evidences of inflam- 
mation are occasionally found in the cavities of the pleura and peri- 
cardium in severe and protracted cases, and that the cavities of the 
heart are sometimes full of blood. 

The sub-maxillary and bronchial glands are generally swollen and 
soft, and in one case Dr. Cheyne found a quantity of glutinous matter 
surrounding the thyroid gland, and passing from behind it round the 
trachea. 

389. Now, from the morbid appearances I have mentioned, there 
cannot be much doubt of the pathology of the disease : that it consists 
of inflammation of the mucous membrane, giving rise to a peculiar 
secretion, and exciting spasmodic action ; and the result is a great im- 
pediment to the ingress of air, to its access to the minute bloodvessels, 
and a less perfect aeration of the blood. 

Dr. Copland has given an admirable series of inferences from the 
post-mortem appearances, which I shall make no apology for quoting : — 

" 1. That the mucous membrane itself is the seat of inflammation 
of croup ; and that its vessels exude the albuminous or characteristic 
discharge, which, from its plasticity, and the effects of temperature, 

1 Dr. Francis, New York Med. and Pbys. Journal, vol. iii. p. 56. 



270 croup- 

and the continued passage of air over it, becomes concreted into a falso 
membrane. 

" 2. That the occasional appearance of bloodvessels in it arises from 
the presence of red globules in the fluid when first exuded from the 
inflamed vessels, as may be ascertained by the exhibition, upon the 
approach of the symptoms, of a powerful emetic, which will bring away 
this fluid before it has concreted into a membrane ; these globules 
generally attracting each other, and appearing like bloodvessels, as the 
albuminous matter coagulates on the inflamed surface. 

" 3. That the membranous substance is detached in the advanced 
stages of the disease, by the secretion from the excited mucous follicles 
of a more fluid and less coagulable matter, which is poured out between 
it and the mucous coat ; and as this secretion of the mucous cryptge 
becomes more and more copious, the albuminous membrane is the more 
fully separated, and ultimately excreted, if the vital powers of the res- 
piratory organs and of the system are sufficient to accomplish it. 

" 4. That subacute or inflammatory action may be inferred as having 
existed, in connection with an increased proportion of fibro-albuminous 
matter in the blood, whenever we find the croupal productions in the 
air-passages ; but that these are not the only morbid conditions consti- 
tuting the disease. 

" 5. That, in conjunction with the foregoing — sometimes only with 
the former of them in a slight degree — there is always present, chiefly 
in the developed and advanced stages, much spasmodic action of the 
muscles of the larynx, and of the transverse fibres of the membranous 
part of the trachea, which, whilst it tends to loosen the attachment of 
the false membrane, diminishes, or momentarily shuts the canal (of the 
lar3 r n\) through which the air passes into the lungs. 

"6. That inflammatory action may exist in the trachea, and the ex- 
udation of albuminous matter may be going on for a considerable time 
before they are suspected, the accession of the spasmodic symptoms 
being often the first intimation of the disease ; and these, with the effects 
of the previous inflammation, give rise to the phenomena characterizing 
the sudden seizure. 

"7. That the modifications of croup may be referred to the varying 
degree and activity of the inflammatory action, the quantity, the fluidity, 
or plasticity of the exuded matter, the severity of spasmodic action, and 
to the predominance of either of these over the other, in particular cases, 
owing to the habit of body, temperament, and treatment of the pa- 
tient, &c. 

" 8. That the muco purulent secretion, which often accompanies or 
follows the detachment and discharge of the concrete or membranous 
matters, is the product of the consecutively excited and slightly in- 
flamed state of the mucous follicles, the secretion of which acts so bene- 
ficially in detaching the false membrane. 

"9. That a fatal issue is not caused merely by the quantity of the 
croupal productions accumulated in the larynx and trachea, but by the 
spasm, and the necessary results of uninterrupted respiration and cir- 
culation through the lungs. 

" 10. That the partial detachment of fragments of membrane, par- 






croup. 271 

ticularly when they become entangled in the larynx, may excite severe, 
dangerous, or even fatal spasm of this part, according to its intensity, 
relatively to the vital powers of the patient ; and that this occurrence 
is most to be apprehended in the complicated states of the malady, 
where the inflammatory action, with its characteristic exudation, spreads 
from the fauces and pharynx to the larynx and trachea ; the larynx 
being often chiefly affected in such cases, and, from its irritability and 
conformation, giving rise to a more spasmodic and dangerous form of 
the disease. 

"11. That the danger attending the complication of croup is to be 
ascribed not only to this circumstance, but also to the depression of vital 
powers, and the characteristic state of fever accompanying most of them, 
particularly in the more advanced stages. 

" 12. That irritation from partially detached membranous exudations 
in the pharynx, or in the vicinity of the larynx or epiglottis, may pro- 
duce croupal symptoms in weak, exhausted, and nervous children, with- 
out the larynx or trachea being materially diseased; and that even the 
sympathetic irritation of teething may occasion the spasmodic form of 
croup, without much inflammatory irritation of the air-passages, parti- 
cularly when the prima via is disordered, and the membranes about the 
base of the brain are in an excited state. 

" 13. That the predominance in particular cases of some one of the 
pathological states noticed above (5) as constituting the disease, and 
giving rise to the various modifications it presents, from the most in- 
flammatory to the most spasmodic, may be manifested in the same case, 
at different stages of the malady, particularly in its simple forms, and 
in the relapses which may subsequently take place ; the inflammatory 
character predominating in the early stages, and either the mucous or 
the spasmodic, or an association of both, in the subsequent periods. 

" 14. That the relapses which so frequently occur, after intervals of 
various duration, and which sometimes amount to seven or eight, or are 
even still more numerous, may each present different states or forms of 
the disease from the others; the first attack being generally the most 
inflammatory and severe, and the relapses of a slighter and more spas- 
modic kind ; but in some cases this order is not observed, the second or 
third, or some subsequent seizure, being more severe than the rest, or 
even fatal, either from the inflammation and extent of exudation, or 
from the intensity and persistence of the spasmodic symptoms, most 
frequently from the latter circumstance." 

We find, then, that the cause of the peculiar sound of the cough and 
sibilant breathing is not simply that the lining membrane is inflamed 
and coated with lymph, but also because the larynx and trachea are 
spasmodically affected, and it is most important to bear this in mind. 1 
Dr. Stewart remarks, that " the cough, or the peculiar sound so re- 
markable in expiration in croup, is observed to exhibit two kinds of 
sound : the first acute, from the active spasmodic contraction of the 
muscles of the larynx, excited at first by the column of expired air; the 
grave, which succeeds it, from the forced enlargement of the glottis, by 

1 Desruelles, Traits du Croup, p. 170. 



272 croup. 

the shock of the same column of air overcoming the contraction of the 
muscles." 1 Dr. Stokes considers the "cause of obstruction in this dis- 
ease to be more spasm than effusion of lymph," and adduces in proof 
the temporary suppression of the sibilant breathing which follows vom- 
iting. 

3§0. It is not very easy to explain satisfactorily why children are so 
much more liable to the disease than adults. Dr. Cheyne considers that 
in the latter " the constitution is, in a great measure, secured from croup 
by the increase and vigor which the larynx and trachea acquire at 
puberty." This might explain their immunity from spasm, but surely 
not from inflammation and the exudation of plastic lymph. 

Dr. Stokes suggests that it may be owing to the preponderance of 
white tissues in children, and to these tissues possessing the greatest 
reproductive power. "In the child, too, there may be a greater relation 
between the physiological, and consequently the pathological states of 
the mucous membrane of the larynx and trachea, and their subjacent 
(white) tissues, than in the adult ; and the same condition which deter- 
mines the progressive development of the larynx up to the period of 
puberty, may also predispose the mucous surface to the plastic or forma- 
tive irritations." 2 I confess I do not think the explanation altogether 
satisfactory, nor have I any better to offer. I may add the fact that 
the disease attacks animals : dogs, cats, lambs, horses, and cows, accord- 
ing to Duval, Rush, Valentin, Youatt, &c, especially the young ; and 
a similar disease is said by Duval, Jurine, Albers, Porter, &c, to have 
been induced by the injection of stimulating fluids into the trachea. 3 

391. Causes. — The principal causes appear to be constitutional apti- 
tude, exposure to a cold, damp, changeable atmosphere, insufficient 
clothing, and epidemic miasma. 

No doubt that children of an irritable, nervous habit, and great sus- 
ceptibility, are the most liable to its attacks. Contrary to M. Barrier's 
statement, children are very liable to a return of the disease, and dif- 
ferent children in the same family sometimes share the liability. One 
of my own children has had three or four attacks, and another two ; the 
predisposition has ceased, however, with advance in age. There does 
not appear to be any ground for attributing it to hereditary influence. 

It prevails much in countries or localities exposed to great vicissi- 
tudes of weather : Savoy, Switzerland, the east of England, northwest 
of Europe generally, the middle and south of France, the north of Italy, 
&c, are countries in which it is very prevalent. In towns, too, it is more 
frequent than in the country ; it is common in London, Edinburgh, 
Leith, Dublin, &c; and more so in the low, damp parts of towns. I 
am informed that it is rare in the north of Ireland ; but Underwood 
mentions that it infests Mullingar. 

It is more common during winter than summer, owing, probably, to 
the frequent changes of weather, and the prevalence of east and north- 
east winds. 

I have no hesitation in saying that the fashion of clothing children 

1 Diseases of Children, p. 75. 2 Diseases of the Chest, p. 211, note. 

3 Valentin, Sur le Croup, p. 464. 



croup. 273 

lightly, exposing their legs, arms, and necks, under the foolish notion 
of hardening them, is extremely favorable to the production of croup. 
Dr. Eberle has given a striking illustration of this in the case of a 
German settlement in America, "who are in the habit of clothing their 
children in such a manner as to leave no part of the breast and lower 
portion of the neck exposed. During a practice of six years among 
this class of people, I recollect having met but a single case of this 
affection, and this case had occurred in a family who had adopted the 
present universal mode of suffering the neck and superior portions of 
the breast to remain uncovered." 1 

The suppression of cutaneous eruptions, the breathing of noxious 
gases, swallowing boiling water, &c, are all occasional causes of the 
disease. 

It may attack children in perfect health, or those whose constitution 
has been weakened by previous disease ; and it not unfrequently occurs 
during an epidemic of influenza or scarlatina, primary in the first, 
secondary in the latter, or as an extension from the neighboring parts. 

Lastly, it has prevailed epidemically at different times to a consid- 
erable and fatal extent. The principal epidemics of which we have 
authentic account are those of Paris in 1556 (Baillou); Cremona, in 
1747 (Ghisi); Cornwall, in 1748 (Starr); Upsal, in 1762 (Rosenstein); 
Frankfort, in 1764 (Van Bergen); Sweden, in 1768-72 (Wahlbom and 
Baeck) ; Wertheim, in 1772 (Zobel) ; in Gallicia, in 1778 (Hirschfeld); 
Clausthal, in 1783 (Boehmer) ; United States, in 1805 (Barker) ; Stutt- 
gard, in 1807 (Autenrieth) ; Saxony, in 1807-8 (Albers) ; and in 1811 
(Schundtmann) ; 2 at Vienna, in 1807-8 (Golis); and in Maryland, in 
1807 (Chatard). 

Several partial or local epidemics have since occurred, but none so 
general as the above, that I am aware of. Dr. Vauthier has published 
an account of the epidemic which prevailed in the Hopital des Enfans 
at Paris in 1846-7. 3 

Several authors, as Wichman, Boehmer, Field, and others, maintain 
the contagiousness of croup ; but this is denied by the majority of 
writers, at all events in the case of primary croup. Certain forms of 
diphtheritic inflammation of the fauces and pharynx are undoubtedly 
contagious ; and as the inflammation and exudation sometimes spread 
to the larynx, constituting secondary croup, it may be so far regarded 
as sharing in the same mode of propagation. 

392. Modifications and Complications. — I shall now proceed to con- 
sider the modifications of croup, i. e. croup with certain of its symptoms 
predominating sufficiently to give a peculiar character to the attack. 

I. Croup, with Predominance of Inflammatory Symptoms — the 
acutely inflammatory croup of some authors. — This is nearly the 
severest form of the disease, attacking plethoric children of a sanguine 
temperament, and perhaps at a more advanced age. It is preceded by 
chilliness, horripilation, and rigors, and characterized by a more con- 

1 Diseases of Children, p. 347. 

2 Albers, de Trackseitide, p. 70. Valentin, Sur le Croup, p. 402. 

3 Archiv. Ge"n. de M6d., May and June, 1848. 

18 



274 croup. 

tinuous and unremitting severity of symptoms, by strength and rapidity 
of pulse, heat of skin, difficult and forcible respiration, redness or 
lividity of cheeks and lips, and the inflammatory appearance of the 
blood taken from the child. 

"When limited, as it may be, to the larynx, it has been called by 
Guersent and others laryngeal croup, and the symptoms connected with 
the respiration, voice, and cough, are peculiarly severe ; the pain and 
swelling of the larynx are remarkable, and convulsions occasionally 
occur. The attack may terminate fatally in twelve hours, or be pro- 
longed to four or five days, but rarely longer. 

On the other hand, the disease may be confined to the trachea, con- 
stituting the tracheal croup of continental writers, and having a less 
rapid and less fatal progress, with some variation in the symptoms. 
For instance, although the cough and breathing are sonorous, they have 
not the brazen sound of ordinary croup, and the voice is far less affected ; 
the sense of suffocation is not so oppressive. 

Pain, or a burning sensation, is felt along the trachea; the croupy 
sound of breathing will be heard if the stethoscope be applied over the 
trachea, and there is severe inflammatory fever present. The attack 
may be prolonged to twelve or fifteen days ; and in some cases it has 
subsided into a chronic form, or, passing downwards, has terminated in 
bronchitis. 

ir. Croup, iviih a Predominance of Nervous or Spasmodic Symptoms. 
— The attack may come on like ordinary croup, with feverishness, cough, 
&c. ; or, as I have more frequently found, the child may go to bed 
perfectly well, and in the course of an hour or two may awake with 
perfectly formed croup, hoarse voice, ringing cough, dyspnoea, and 
threatened suffocation, which, if not relieved by treatment, will continue 
during the night, and have a remission during the clay. There is, on 
the whole, less fever, but not less distress ; and if the attack be neg- 
lected, it will run a course similar to ordinary croup, characterized by 
greater dyspnoea, louder cough, and more sibilant respiration, and 
prove fatal, as in the other forms. 1 

Fortunately, if taken early, it is far more manageable ; the spasmodic 
irritation may be relieved before there has been time for false mem- 
branes to form, and with the relief of the spasm the inflammation may 
either disappear or be modified. Thus, with my own children, I have 
repeatedly subdued the croupal affection in the course of two hours, and 
there remained only catarrh with hoarseness. 

393. Now let us notice the diseases with which croup may be com- 
plicated, or, in other words, its secondary affections. These are not 
numerous, but they add much to the severity and danger of the disease. 

I. Bronchitis. — I have already mentioned that morbid appearances 
indicating inflammation of the bronchial tubes are found even in cases 
where the croupy exudation does not extend below the trachea ; and, in 
practice, we find that this complication is not very uncommon. It seems 
more frequent in young and delicate children, and is marked by the 
predominance of catarrhal symptoms from the beginning generally. 

1 Blaud, Reclierches sur le Croup, p. 312. 



croup. 275 

"We find the croup, dyspnoea, and hoarseness much as in an ordinary 
case ; but there is more wheezing in the chest, and more expectoration. 
There is generally less fever, the skin is cooler, and the throat and 
larynx seem less permanently the seat of the mischief. After three or 
four days, the cough is softer, the paroxysms shorter, and the expecto- 
ration increased. If the croupy sound be not very loud, we shall be 
able to hear bronchial rales in one or both lungs. The chest is resonant 
on percussion. 

In the progress of the attack, either affection, the croup or the bron- 
chitis, may predominate, and give to it its peculiar character, i. e., it 
may merge into a case of marked croup, such as I have described, with 
some bronchitic symptoms, or it may degenerate rather into a bronchitic 
affection, with very little of croup. The latter is much safer, for in the 
former we have the danger from the croup augmented by the disease of 
the air-tubes. 

394. II. Pneumonia. — This disease complicated five-sixths of the 
cases collected by MM. Hache and Rilliet and Barthez; and, according 
to the observations of Blache, Guersent, Trousseau, and others, it is the 
most frequent complication of croup ; and I need not say how fearfully 
it increases the danger of the primary disease. 

It seldom occurs at the commencement of the disease, or during the 
precursory stage, but makes its inroad in the course of the second, or 
towards its termination. 

The pneumonia may be either general or lobular, and this, together 
with the loud croupy sound, renders its detection often extremely diffi- 
cult. We ought to examine the chest daily, to seize upon a moment of 
comparative quiet ; and, if we can avail ourselves of the temporary sus- 
pension which follows vomiting, as suggested by Dr. Stokes, we may be 
able to detect the crepitant rale in the portion of the lung occupied by 
the inflammation. 

The only symptoms which will indicate the deeper mischief will 
probably be an increase of fever, and a more rapid sinking of the vital 
powers. 

The cough is sometimes less ringing ; but the sibilant breathing, the 
hoarseness, and the fever are as well marked as in the other cases. The 
disease thus complicated runs a very rapid and almost universally fatal 
course, without remission or mitigation. 

395. in. Other complications have been noticed, but they occur much 
less frequently ; thus, Cheyne, Condie, and others, mention the occur- 
rence of pleuritis ; several authors speak of emphysema ; others of 
partial rupture of the trachea ; and Martin 1 of a case in which vomit- 
ing of blood occurred. 

396. Secondary Croup. — So much for the complications of croup ; 
but we must not forget that croup may complicate other diseases, and 
be to them a secondary affection. 2 Thus, for example, in some cases of 
diphtherite, cynanche maligna, scarlatina maligna, cynanche tonsillaris, 
or cynanche pharyngea, the inflammation, which, in those parts, gives 

1 Rec. Period, de la Soc. de Med. de Paris, April, 1810. 

2 Albers, Comment, de Trachseatide, p. 69. 



276 croup. 

rise to the ash-colored or whitish membranous exudation, may extend 
itself to the larynx and trachea, giving rise to croup, and adding a for- 
midable complication to the primary affection. 

Again, croup, though rarely, supervenes upon thrush ; in this case it 
takes its character from the state of the constitution induced by the 
primary disease, and, generally speaking, the pharynx and larynx are 
more severely implicated than the trachea. The accompanying fever 
is of an ataxic or adynamic type. 1 

It also occurs in the course of several of the exanthemata ; during the 
first or eruptive stage of measles, miliary eruption, scarlatina, as I have 
mentioned, smallpox, &c, according to the testimony of many authors. 
In the latter case it comes on most frequently during the suppurative 
stage of confluent smallpox, and, as in diphtherite, the inflammation 
extends from the pharynx to the larynx. 

Some cases of erysipelas of the fauces, in which the extension of the 
inflammation gave rise to croup, are related by Forester, Latour, Ste- 
venson, and Gibson. 

Dr. Vauthier relates eight cases of secondary croup out of thirty- 
seven. Three complicated measles ; two, pneumonia and typhoid fever; 
one, scarlatina ; and one, hooping-cough. 

397. The morbid changes discoverable after death in secondary croup 
are of the same character as in the primary affection, but less marked ; 
there is less redness ; the softening or thickening of the mucous mem- 
brane is less extensive ; the false membranes are yellowish, and of 
smaller extent, thinner, less adherent, and softer than in the disease 
just described. They seldom occupy the entire larynx, but often the 
interior portion of the epiglottis, and the superior part of the larynx, 
as far as the chordos vocales, or the ventricles of the larynx. In one 
case out of eleven only did Rilliet and Barthez detect them at the infe- 
rior portion of the trachea, and in another in the bronchial tubes. 

398. The symptoms of the secondary croup are a good deal mo- 
dified, and resemble more some of the forms of laryngitis. Thus, the 
cough is sometimes dry, sometimes moist, easy, or painful and hoarse, 
but it has less of the metallic ringing sound ; the respiration is difficult 
and hissing, but without the loud sibilant sound of primary croup ; the 
voice is less changed. Rilliet and Barthez mention that in five of these 
cases it was unaltered ; in two others it was nasal, embarrassed, but not 
extinguished ; in three it was muffled, and in one it was extinct ; with- 
out any peculiarity in the situation of the false membrane to explain 
the difference. The expectoration varies ; there may be some mucous 
or muco-puriform matter thrown off, but there is rarely or never any 
shreds of lymph. 

On inspecting the fauces, however, in these cases, we shall find there 
the primary affection in the form of inflammation (and perhaps ulcera- 
tion) of the tonsils, uvula, and palate, with a gray or yellowish exuda- 
tion of lymph ; the parts are swollen, and of a dark red color, and there 
is considerable difficulty in swallowing. 

1 Med. Obs. and Inq. by Dr. Rush, vol. ii. p. 376. Ferrier, Med. Hist, and Reflec- 
tions, vol. iii. p. 205. 



croup. 277 

Dr. Stokes has given a comparative view of the symptoms of primary 
and secondary croup, which I shall take the liberty of extracting : — 

" 1. In primary croup the air-passages are primarily engaged ; in 
secondary croup the laryngeal affection is secondary to disease of the 
pharynx and mouth. 

" 2. In the former the fever is symptomatic of the local disease ; in 
the latter the local disease arises in the course of another affection, 
which is generally accompanied by fever. 

" 3. In the former che fever is inflammatory ; in the latter typhoid. 

" 4. In the former there is necessity for antiphlogistic treatment, and 
the frequent success of such treatment ; in the latter, incapability of 
bearing antiphlogistic treatment, necessity for the tonic, revulsive, and 
stimulating modes. 

" 5. The former is spasmodic, and in certain situations endemic, but 
never contagious ; the latter, constantly epidemic and contagious. 

" 6. The former is a disease principally of childhood ; by the latter 
adults are commonly affected. 

" 7. In the former the exudation of lymph spreads to the glottis 
from below upwards ; in the latter from above downwards. 

" 8. In the former the pharynx is healthy ; in the latter it is dis- 
eased. 

" 9. In the former dysphagia is either absent or very slight ; in the 
latter it is constant and severe. 

" 10. In the former, the catarrhal symptoms are often precursory to 
the laryngeal ; in the latter, the laryngeal symptoms supervene, without 
the pre-existence of catarrh. 

" 11. In the former, the complication with acute pulmonary inflam- 
mation is common ; in the latter, rare. 

" 12. In the former, the absence of any characteristic odor of the 
breath; in the latter, the breath is often characteristically fetid." 1 

399. Diagnosis. — The pathognomonic symptoms of croup are the 
hoarse voice, the sibilant breathing, and the rough metallic ringing 
cough ; which, in the third stage, become the whispering voice, wheez- 
ing, hissing respiration, and husky, choking cough. 

I. It may be distinguished from spasm of the glottis by the catarrhal 
stage, by the hoarse voice, by the sibilant respiration, and by the ring- 
ing cough; in spasm of the glottis there is no catarrh, inspiration only 
is difficult ; the crowing sound is quite different from the expiratory noise 
in croup ; there is no cough, and the voice is unaltered. 2 

ir. In simple laryngitis the cough and voice are rough and hoarse, 
but very unlike the ringing, metallic cough of croup ; the respiration is 
sometimes difficult, but rarely, if ever, sibilant; there is fever, expecto- 
ration, and no such paroxysms of suffocation as in croup. 

in. Primary croup differs from secondary croup in the absence of 
sore throat, inflamed fauces covered with false membrane, the peculiar 
characters of the original disease, and in the greater intensity of the 

1 Diseases of the Chest, p. 206. 

2 Albers, Comment, de Trachseatide, &c, p. 50. 



278 croup. 

symptoms, fever, dyspnoea, and cough. 1 I have already given Dr. 
Stokes's parallel between the two affections. 

IV. In pertussis there is hurry of respiration, but neither the diffi- 
culty nor the sibilant sound; the cough, though loud, has not the pecu- 
liar metallic sound, and in the intervals there is complete relief, neither 
hoarseness nor dyspnoea. 

v. If the previous history were obscure, it might be possible to mis- 
take the symptoms resulting from foreign bodies in the trachea for 
croup, but a careful inquiry will generally remove the difficulty, and, in 
addition, the suddenness of the attack, the absence of false membrane 
and of inflammatory fever, with the results of auscultation, will leave but 
little doubt. 

VI. It is, perhaps, impossible to draw the line between croup and the 
laryngitis resulting from swallowing boiling Avater, as in the latter case 
there is an exudation of lymph firmly adherent to the membrane of the 
larynx ; it never, however, extends to the trachea ; and although the 
swollen membrane impedes respiration, still the spasmodic paroxysm is 
wanting. Our best guide will be the previous history of the case. 

400. Terminations and Prognosis. — I. Croup may terminate favor- 
ably in resolution, the fever diminishes, the croup becomes softer, loses 
its croupy sound, and resembles the cough in a slight attack of laryn- 
gitis ; the respiration gradually becomes easier, and expectoration takes 
place. "Most commonly," says Dr. Cheyne, "after the disease has 
arrived at its height, the decline is, as it were, a retrogression of the 
attack ; the skin is moist, the fever abates ; the cough becomes loose, 
the breathing easy, and the voice gradually recovers its natural tone." 
Sometimes the crisis is marked by the expectoration of false membrane, 
but this is not always a proof that the disease will subside. 

II. The inflammation may subside in the larynx, but extend itself 
downwards to the large or small bronchial tubes, and the croup will then 
merge in bronchitis or pneumonia. 

III. In the majority of cases, croup ends fatally with the symptoms I 
have already detailed. Marley says that two-thirds die. Vieussieux, 
in 1775, states that, in his early practice, ten cases out of twenty died ; 
Jurine, that one in ten die ; Michaelis and Bard, two out of three. 

In Philadelphia, during the ten years preceding 1845, there occurred 
1150 deaths from croup, or 150 per annum. In Paris, in 1838, the 
deaths were 187 ; in 1839, 286 ; and in 1840, 326. In London, in 
1840, the deaths from croup amounted to 391; and in all England to 
4336. 

Sudden deaths, as I have already stated, may occur from the partial 
detachment of a valve of false membrane, but ordinarily the cause of 
death is a deficiency of air, and consequently the patient dies of as- 
phyxia. 

401. The prognosis, therefore, in all cases of croup, is very serious ; 
the probabilities are against recovery, but in estimating those probabili- 
ties we must take into careful consideration the period of the disease at 
which the child comes under treatment, the intensity of the symptoms, 

1 Pathology of Larynx and Bronchia, p. 16. 



croup. 279 

the degree of fever, the complications, and the extent of the disease, 
and the strength of the constitution. 

If the disease be attacked at the very commencement, it is by no 
means an unmanageable or fatal disease, but will in most cases yield to 
appropriate treatment ; nay, if it be further advanced before we see it, 
yet if it be a mild case, the symptoms marked but not violent, the in- 
flammation limited, the fever moderate, and no complication, the child 
may recover under proper care. 

But if the attack be rapid and severe, the cough violent, the dyspnoea 
intense, and the fever high, and especially if the lungs be affected, and 
time has been lost, there will be but little hope from treatment at any 
period; none if the case have been overlooked for twenty-four hours. 

I cannot quite agree with Rilliet and Barthez that we ought never 
to despair of the life of the patient in croup, nor do I anticipate as 
much benefit from tracheotomy, even as a last resource, as those ex- 
cellent practitioners ; but certainly there are some cases of recovery 
recorded when all hope seemed extinguished, and they appear to have 
been mainly owing to the strength of the patient's constitution. 

402. Treatment. — The indications of cure are : 1. If we are called 
early, to arrest or subdue the inflammatory action, and to prevent the 
formation of false membranes, or the albuminous secretion and accumu- 
lation in the air-passages ; 2. When the time for doing this has passed, 
to procure the discharge of these matters ; 3. To mitigate the spas- 
modic symptoms ; and 4. To support the powers of life in the latter 
stages, so as to enable the system to throw off the matter exuded in the 
trachea. 

403. Our success in the first of these indications depends, I think, 
upon seeing the child early ; if we are present at the very beginning, we 
may almost always cut short the disease. My own children, for exam- 
ple have been attacked five or six times. I always give immediately an 
emetic of tartarized antimony, and afterwards smaller doses to keep up 
the nausea for an hour or two. In no instance has bleeding been neces- 
sary after this, and the attack has never lasted more than two or three 
hours. 

We should, in the first stage, commence by an emetic of ipecacuanha 
or tartar emetic, and keep up a nausea for some time by smaller doses. 
"Emetics," says Dr. Cheyne, "appear peculiarly fitted to answer the 
indications of cure in the first stage of croup. They increase the secre- 
tion from the mucous membrane of the bronchia, while, at the same 
time, they lessen the general tone of the arterial system. Hence they 
are the only true expectorants." 1 

M. Valleix states that of 31 cases in which emetics formed the basis 
of treatment, 15 recovered, while of 22 in which they were rarely given, 
but one recovered. 

By most practitioners the tartar emetic is preferred, and I think with 
reason, because of its peculiar antiphlogistic power ; it may be given in 
doses of a quarter or half a grain every quarter of an hour, until vomit- 
ing is excited, and then continued in doses of an eighth or a twelfth 

1 Pathology of the Larynx and Bronchia, p. 51. 



280 croup. 

of a grain every hour or two. Some German physicians, as Droste, 
Kerting, and Steinmetz, prefer the sulphate of copper ; and Smith, 
Farre, and Francis, recommend the sulphate of zinc. Dr. Meigs uses 
the alum, and speaks most highly of it in doses of a teaspoonful of 
the powder in honey or syrup, and repeated in a quarter of an hour, 
if it do not excite full vomiting. 1 

Dr. Hubbard prefers the turbith mineral (subsulphate of mercury) 
for this purpose. 

404. In the severer cases, or when the emetic fails in changing the 
character of the disease in an hour or two, we must have recourse to 
bloodletting. There is no difference of opinion as to the propriety of 
this practice, but merely as to the mode. Some advise bleeding from 
the arm or jugular vein, as Marley, Cheyne, Porter ; others, as Dr. 
Merriman, cupping ; whilst by the majority leeches are employed. 
Whatever method we adopt, the essential point is to take as much blood 
as will make a decided impression on the disease, and to repeat the 
bleeding if necessary. I prefer leeches applied to the upper part of 
the sternum, where the bleeding can be readily arrested by pressure ; 
and I repeat that it ought to be arrested when the leeches fall off. I 
quite agree with Dr. Condie that " there is certainly no disease in which 
bleeding, when Avell timed, and carried to a sufficient extent, is calcu- 
lated to produce more beneficial effects than in croup. The practitioner 
who, in violent cases, neglects this important measures, and places his 
hopes in any other remedy, or combination of remedies, will have but 
little reason to flatter himself upon his success in the management of 
the disease." 2 

The quantity of blood taken must vary according to the intensity of 
the disease, the strength of the child, and the effects produced. It is 
not desirable to carry it to excess in any stage, but in the first stage it 
is less mischievous to take too much than too little. 

In the eighth volume of the Dublin Medical Journal, and more re- 
cently in his Clinical Medicine, my friend Dr. Graves has called atten- 
tion to the treatment proposed by Dr. Lehman, of Torgau. It consists 
in the immediate application of hot water in the following manner : " A 
sponge, about the size of a large fist, dipped in water as hot as the 
hand can bear, must be gently squeezed half dry, and instantly applied 
beneath the little sufferer's chin, over the larynx and windpipe ; when 
the sponge has been thus held for a few minutes in contact with the 
skin, its temperature begins to sink, and it requires to be dipped again 
in hot water." This is to be continued from ten to twenty minutes, 
and will produce a vivid redness, as if a sinapism had been applied, 
accompanied with a general perspiration, and followed by immediate 
relief of the cough, hoarseness, and dyspnoea. ; ' Since then," Dr. 
Graves observes, " I have repeatedly treated the disease on this plan, 
and with the most uniform success. It is, however, only applicable to 
those cases which are seen at the very onset of the disease ; and you 
must remember, also, that I do not propose it to the total exclusion of 

1 American Journ. of Med. Sciences, Ap. 1847, p. 290. 

2 Diseases of children, p. 305. 



ceoup. 281 

bleeding and tartar emetic, which must be used in the more aggravated 
cases, or in those which are not seen until the disease is somewhat ad- 
vanced." 1 

405. The bleeding may be preceded or followed by a warm bath, 
which, for a time, relieves the oppression, and certainly gives greater 
effect to the other remedies ; and it is peculiarly beneficial when the 
disease is yielding to the treatment. 

Dr. Horace Green, of New York, has proposed the local application 
of nitrate of silver in croup, as well* as in other laryngeal affections. 
Ordinarily he uses a solution of from two scruples to a drachm of the 
crystals of nitrate of silver in an ounce of water, and he applies it at 
first to the fauces and glottis, and afterwards within the larynx, by 
means of a small piece of sponge fastened on a curved rod of whale- 
bone. " The instrument being prepared by suitably saturating the 
sponge with the solution to be applied, and the head of the child being 
firmly held by an assistant, and the base of the tongue depressed by 
a spoon or any other suitable instrument, the operator carries the wet 
sponge quickly over the top of the epiglottis, and on the laryngeal sur- 
face of this cartilage ; then pressing it suddenly downwards and for- 
wards, passes it through the opening of the glottis into the laryngeal 
cavity." 2 This Dr. Green says does not produce the amount of irrita- 
tion we should expect, and he considers it suitable to every stage either 
of simple or complicated croup. He has given several cases, in which 
this treatment succeded. Dr. Blakeman of New York has recorded two 
cases in which it succeeded ; the first requiring three, and the second 
two applications of the solution. 3 Dr. Clarke has related six cases thus 
treated, of which four recovered, and two died. 4 

Dr. Latour has used the solid nitrate of silver to all the parts within 
reach, and afterwards contrived to squeeze some of the solution into the 
larynx. The child recovered. 5 

Dr. J. F. Meigs, of Philadelphia, used a solution of nitrate of silver 
(gr. x to oj) to the fauces, applied with a camel's-hair brush. He does 
not, however, seem to attribute much of his success to this application. 6 
Dr. Townsend proved it of great use in one case. 7 

These are the principal means at our command during the first stage, 
and it is necessary to use them promptly and vigorously, for, as Dr. 
Ferrier observes, the course of genuine croup is very short. If the 
alarming symptoms I have described, are not mitigated during the first 
six hours, the disease will generally prove fatal. It has happened 
several times that I have been called early in the day to patients who 
had become seriously ill only on the preceding evening ; and in such 
cases I have only succeeded once. The proper time for administering 

1 Clinical Med., Lecture xxxix., vol. ii. p. 4. Second edition. 

2 Observations on the Pathology of Croup, p. 83. 

3 New York Med. and Surg. Reporter, &c, Oct. 1847. 

4 American Journ. of Med. Sciences, Ap. 1850, p. 360. 

5 Gazette Med., Aug and Oct. 1846. 

6 American Journ. of the Med. Sciences, Ap. 1847, p. 290. 

7 Ibid., July, 1851, p. 85. 



282 croup. 

relief is when the cough, dyspnoea, and palpitation increase towards ten 
or eleven o'clock in the evening. 1 

406. In the second stage it will be well to have recourse to an emetic, 
and certainly to bleeding, if it has not been practised before. 

Dr. Cheync recommends the employment of tartar emetic in quarter 
or half grain doses every hour, so as to excite vomiting occasionally. 
In this practice Dr. Stokes agrees ; he dissolves a grain of the salt in 
an ounce of distilled water, and gives a dessertspoonful " every quarter 
of an hour, or every half-hour, as the case may be." 2 

Mr. Porter rather prefers nauseating doses of this remedy to those 
which occasion repeated vomiting, and I am inclined to think that after 
the emetic effect has been at first excited, and kept up for an hour or 
two, as much good will be derived from the smaller doses. 

On the other hand, we must not forget that with some children tartar 
emetic produces a very depressing effect. Dr. Stewart mentions that 
he has known "utter and irrevocable prostration and death quickly 
ensuing from its use in young children," and in such cases it may be 
combined with oxymel of squills, or ipecacuanha may be substituted for 
it without danger of similar effects. 

407. Drs. Rush, Hosack, Bard, and other practitioners, have attached 
great value to calomel, alone, or in combination with Dover's powder. 
Dr. Cheyne does not think it of much use ; during two seasons, in which 
he had used it freely during the second stage, all the cases terminated 
fatally. Dr. Stokes observes, that the mercurial treatment of croup is 
insufficient and unnecessary. " The uncertainty of the action of calo- 
mel, the difficulty of producing ptyalism in violent acute inflammation, 
the shortness of the period for the exhibition of the remedy, and the 
various injurious effects of mercurial action on the system at large, are 
sufficient reasons against the employment of this treatment in the croup 
of children ; and when we have so valuable a remedy as the tartar 
emetic, it seems scarcely justifiable to tamper with the case by the 
attempt to produce mercurial action." 3 

Certainly, as a substitute for tartar emetic, it would be of feeble and 
doubtful value ; but I have seen much benefit from it after the vomiting 
or nausea had been kept up for some time, or when the depressing effects 
of the latter had been too decided to permit its prolonged use. MM. 
Bretonneau and Guersent have repeatedly succeeded by the mercurial 
treatment carried to ptyalism ; but the latter author cautions us against 
its use in weak or debilitated constitutions. Mr. Porter speaks well of 
it "in long-protracted and chronic cases, when there is a tendency in 
the mucous membrane to become thickened and changed in structure." 4 
I have generally given it in combination with James's powder and a 
minute portion of Dover's powder, say half a grain of each of the 
former, with a third of a grain of the latter, every three or four hours. 
Eberle prefers the combination of calomel with tartar emetic, in the 
proportion of four or six grains of the former with a fourth of a grain 

1 Mod. Hist, and Reflections, vol. Hi. p. 139. 

2 Diseases of the Chest, p. 217. 

3 Diseases of the Chest, p. 218. 

4 Surgical Pathology of the Larynx and Trachea, p. 45. 



croup. 283 

of the latter, every fifteen minutes, until vomiting is excited, in the case 
of children from two to five years old. He further states that he 
" administered the lobelia inflata, with a view to its emetic operation, 
with the happiest effects." 1 With the same object, decoction of senega, 
sulphate of zinc or copper, have each its advocates. 

408. Counter-irritation is certainly of great use, but some difference 
of opinion exists as to the best course. Some prefer strong liniments 
to the throat and chest. Dewees recommends turpentine, hartshorn, or 
the mustard and vinegar poultice. Others, as Drs. Ferrier, Underwood, 
&c, recommend the application of a blister ; but Mr. Porter objects to 
these, on account of the time required to produce their effects, and on 
account of the danger of applying them in the immediate neighborhood 
of inflammation, but he admits their value when the lungs are congest- 
ed. 2 Rilliet and Barthez, and Bouchut, disapprove of them as rarely 
useful, and they mention that the denuded surface is sometimes covered 
with an exudation resembling that in the larynx. 3 

During the first stage, and the early part of the second, I conceive 
that blisters are quite inadmissible ; but after the employment of bleed- 
ing and tartar emetic, and the lowering of the system by these means, 
especially if there be any tendency towards bronchial complication, I 
have certainly seen benefit from the mustard poultices and blisters. 

409. The action of purgatives upon the system generally, and upon 
the local disease, is beneficial, and should, therefore, never be neglected ; 
but we cannot depend upon them as a main part of the treatment. If 
neither the tartar emetic nor calomel act upon the bowels, some brisk 
warm cathartic should be given; but, on the other hand, should diar- 
rhoea result from the above treatment, it must be controlled by some 
astringent and cordial medicines. 

410. Now if, under this treatment, the disease give way, and the cough 
become softer, the breathing easier, and the fever less, we may diminish 
the frequency of the doses and their amount, or we may simply confine 
ourselves to expectorant remedies, decoction of senega, squills, ammo- 
nia, and small doses of ipecacuanha, &c, with an occasional warm bath, 
and a little James's powder two or three times a day, so long as the 
fever lasts, with due attention to the stomach and bowels, and a careful 
regulation of the diet. 

411. But suppose the symptoms continue unmitigated, and there is 
evidence that they are not entirely spasmodic, we shall have but too 
much reason to fear that the pseudo-membranous exudation has taken 
place, and some modification of the treatment will be necessary. It will 
be of little use to continue the depletion further, as the result will be 
rather loss of strength than benefit ; but we may continue the calomel 
and the expectorants I have already mentioned. 

If the fits of coughing be severe and suffocative, an occasional emetic 
will be of service in loosening and perhaps expelling the lymphy exuda- 
tion. The continued use of tartar emetic must depend upon the circum- 

1 Diseases of Children, p. 359. 

2 Surgical Pathology of Larynx and Trachea, p. 45. 

3 Mai. de l'Enfance, p. 269. 



284 croup. 

stances of the case. The inhalation of aqueous or medicated vapors 
has been recommended by high authority, that of Hume, Pearson, 
Rosen, Pinel, Golis, &c. ; they ought to be merely emollient in the first 
stage and early part of the second, but afterwards slightly stimulant. 
It may be useful, also, in the spasmodic form of the disease, but must 
not impede the employment of antispasmodics by the mouth or in ene- 
mata. 

Dr. Budd, of Bristol, recommends converting the bed of the patient 
into a vapor bath, and giving an emetic every four hours. 1 

A warm bath will also be found useful occasionally, but in some cases 
it seems to aggravate the dyspnoea. 

412. The use of narcotics in this stage requires great care ; they 
should be given in small doses, and only those should be employed upon 
whose action we can reckon most certainly, and in the form the most 
uniform in its operation ; for this reason they had better not be given 
in clysters. Dover's powder may be combined with the calomel or with 
camphor, or camphor with James's powder and hyoscyamus ; or a drop 
or two of laudanum added to the expectorant mixture will probably 
answer the purpose best. 

Dr. Purefoy has related a case of croup in which much benefit was 
derived from the iodide of potassium, after bloodletting, emetics, and 
blisters. He gave one grain, combined with a grain of hyd. c. creta, 
every two hours. 2 

Mr. Hird speaks highly of the effects of alkalis in allaying spasm, 
and promoting the absorption of the exudation ; he gives ten or fifteen 
minims of the liq. potassse every four hours. 3 

Dr. Condie recommends a tobacco poultice to the throat, " composed 
of the moistened leaves of tobacco, mixed with the crumbs of stale 
bread or ground flaxseed. The patient must be carefully watched, lest 
the depressing effects be excessive." 

The hydro-sulphuret of ammonia is said by Chamerlat and Condie to 
be beneficial in this and the next stage. 

Dr. John Archer, of Maryland, strongly recommends senega root as 
an almost infallible remedy in cases of croup, and almost all American 
writers speak favorably of it. I can bear witness to its value, but it is 
rather as an expectorant, after the first violence of the inflammation 
has been subdued. It may be advantageously combined with antimo- 
nials, or ipecacuanha, or squills, as in the following formula: — 

R. — Decoct, senegse ^ij. 

Oxymel scillse ^ij. 

Vini ipecac. 3J, or Liq. antimon. 311J. — M. 
Cap. cochl. i. parv. 2ndis vel 3tiis horis. 

Drs. Maclean and M. Constance speak very highly of tincture of 
digitalis ; the former gentleman tried it in one case, and the latter in 
two, and all recovered. It may be a useful adjunct in the first, and 

1 Med. Times and Gazette, June 19, 1852, p. 611. 

2 Dublin Journal, May, 1846. 3 Lancet, December 5, 1846. 



croup. 285 

early part of the second stage, but it would, I think, be unwise to depend 
upon it to the exclusion of other remedies. 

Should the active measures hitherto recommended cause much depres- 
sion, it may be necessary to make a cautious use of stimulants or tonics. 

413. In the third stage, the three latter indications of cure are to 
be kept in view. The expectorants must be continued, and occasionally 
vomiting should be excited. It is advantageous at this period to combine 
them with antispasmodics or stimulants, such, for instance, as camphor, 
musk, assafcetida, &c. ; or the latter may be given in the form of enema. 

Inhalation of the vapor of ammonia, camphor, or ether, with aqueous 
vapor, has often been found useful, and occasionally the fumes of vinegar 
alone, or mixed with camphor. 

Tepid baths may be used occasionally, and if there be much collapse, 
a little flour of mustard should be added to them. 

If we have any evidence of the expectoration of lymph, it may be 
promoted by emetics ; and for the same purpose Sentin and Thilenius 
recommended sternutatories. 

Blisters may be applied to the neck or sternum, and during this 
stage they act as stimulants as well as counter-irritants ; or strong rube- 
facients to the throat, chest, or between the shoulders, may be employed. 

Stimulants will certainly be necessary as the disease advances, and 
probably the best we can employ will be camphor, ammonia, or musk. 

Harden, Schmidt, and Copland, speak well of cold affusion to the 
head by way of relieving the congestion of that organ which results 
from impeded respiration, and so diminishing the chance of convulsions. 

The bowels should, of course, be kept free throughout each stage. 

The persistence of the more active part of the treatment during the 
third stage is generally undesirable ; it must depend upon the character 
of the symptoms and the strength of the patient. If the bowels be not 
too much affected, the calomel may be continued, and an occasional 
emetic exhibited ; but in general we have to act more indirectly, and 
through the medium of the constitution, aided by counter-irritants. 

414. Thus we see the means at our disposal which offer a probability 
of success are not very numerous. Early vomiting, continued nausea, 
bloodletting, warm baths, counter-irritants, expectorants, tartar emetic, 
calomel, some few antispasmodics and stimulants, compose the whole 
list ; but these, used judiciously, promptly, and vigorously at first, and 
more cautiously afterwards, afford a reasonable hope of success if we 
are summoned sufficiently early. 

415. The modifications of croup will require nearly the same treat- 
ment. When the attack exhibits more of a spasmodic character, the 
remedies need not be quite so severe ; emetics at the beginning are 
equally necessary ; but in many cases we may dispense with blood- 
letting, not, however, if any of the croupy character remains. Next to 
emetics, counter-irritants, expectorants, antispasmodics, and cathartics 
will afford the greatest relief. 

Dr. Copland recommends the administration of bark, and, no doubt, 
in the more advanced stage, when there is much sinking, it is calculated 
to be of use. 

416. When croup is complicated with bronchitis, pneumonia, or pleu- 
risy, the same principles of treatment will apply ; but in addition, local 



286 croup. 

remedies will be necessary. Fortunately, tartar emetic, calomel, counter- 
irritants, &c, are as effectual in these diseases as in croup. 

I do not think that children so affected bear depletion to any great 
extent; but, with regard to this and the rest of the treatment, we must be 
guided by the intensity of the attack and the strength of the constitution. 

417. Secondary croup requires a more skilful modification of treat- 
ment ; it is seldom that very active means can be employed. In addi- 
tion to the remedies for the primary disease (to be hereafter mentioned), 
we must have recourse to an occasional emetic, to small doses of tartar 
emetic, expectorants, counter-irritants, stimulants, topical applications, 
&c. I shall have an opportunity of alluding to this part of my subject 
in another part of this volume, when speaking of diphtherite, &c. 

418. But we have seen that a portion, at least, of the disease con- 
sists in the mechanical impediment to the passage of air into the lungs, 
that this obstacle is chiefly in the larynx, and that the fatality of the 
disease is partly owing to the inefficient aeration of the blood in conse- 
quence. Now, it is a very natural and plausible question whether this 
difficulty might not be avoided by an operation ; in other words, whe- 
ther the operation of tracheotomy, by admitting air freely to the lungs, 
might not, even in the third stage, prolong life and increase the chances 
of cure. 

Accordingly, the question has occupied the attention of most writers, 
and led to different conclusions. It appears to have been first proposed 
by Home and Michaelis; and it has been practised in Spain, Denmark, 
Germany, America, and in Geneva, Brest, Lyons, Paris, London, Dub- 
lin, &c. 

I shall mention the opinions of some of the principal authorities. Dr. 
Cheyne is opposed to it because he thinks it would be useless unless the 
membrane could be removed, which, in most cases, would be impossible, 
and in others superfluous, on account of its rapid reproduction. He 
condemns, also, the danger of the operation in young children. 1 

Dr. Dewee's saw the operation performed twice by Dr. Physic, under 
favorable circumstances, but without success; and he objects to it as 
being uncalled for in the earlier stages, and unavailing in the later. 2 

Dr. S. Merriman seems more favorable to it. He mentions that, 
" in a case which he attended along with Mr. Lightfoot, this operation 
was proposed as a last and only remedy; and it was performed by the 
late Mr. Chevalier, and was perfectly successful." 3 

A successful case is also mentioned in the third volume of the Medico- 
CMrurgical Transactions. 

Mr. Porter has investigated the matter with his usual ability, as to 
the necessity of the operation, the symptoms requiring it, the period at 
which it ought to be performed, and the amount of success which has 
attended it; and, having had extensive experience of the disease, and 
moreover having performed the operation as a last resource himself, he 
has arrived at the conclusion that " the operation does not afford suffi- 
cient prospect of benefit to admit of our having recourse to it." 4 

1 Pathology of Larynx and Bronchia, p. 41. 2 Diseases of Children, p. 480. 

3 Underwood on Diseases of Children, p. 451. 

4 Surgical Pathology of Larynx and Trachea, p. 57, el seq. 



croup. 287 

Mr. Carmichael lias recorded a case in which he performed the opera- 
tion with success, and a second which was unsuccessful. 1 

Dr. Stokes expresses his decided dissent from the performance of 
tracheotomy : " Experience has shown that the operation has failed in 
the great majority of cases ; and it is obvious that, with our present 
knowledge of the nature of the disease, we can scarcely hope for good 
from its performance. 2 

Dr. Stewart is evidently unfavorably disposed to the operation. 3 Dr. 
Condie admits that in severe cases, when timely performed, it may save 
the life of the patient ; and he mentions Drs. Hosack and Farre among 
those favorable to it. 4 

Dr. J. F. Meigs has seen the operation performed three times, and 
in two of the cases the children recovered.* But he mentions that it 
had been performed in Philadelphia in eight cases prior to 1848, and in 
four cases during that year (exclusive of his three cases), and in all un- 
successfully. 

Dr. Bigger has recently recorded a successful case in the Dublin 
Medical Press. 6 

Dr. Coley relates a case in which he performed the operation, and 
the patient died. 7 

Mr. W. Craig has published a case in which he operated successfully. 8 
The child was set. 7, and the false membrane had extended below the 
incision, but was removed through it. 

• 419. On the Continent, however, the operation has found some ad- 
vocates, and apparently met with somewhat greater success. Caron 
Marigault, Senn, Maslhieurat, Berard, Petit, Rilliet and Barthez, Bar- 
rier, Guersent, Bouchut, Thore, R. Latour, &c, are in favor of it ; but 
it has also powerful opponents in Vieussieux, Double, Albers, Jurine, 
Royer Collard, Bricheteau, Becquerel, Bondet, &c. 

In the cases in which tracheotomy was performed by Guersent and 
the "internes," in the Hopital des Enfans at Paris, in 1841, the opera- 
tion, while it was of no advantage whatever when the pseudo-membra- 
nous exudation extended to the bronchi, appeared in many cases to 
accelerate the fatal termination by inducing severe bronchitis, or an exces- 
sive secretion of mucus in the bronchi, pneumonia, or convulsions; while 
in many cases the patient died immediately after the operation, without 
any local lesion existing to which the fatal termination could be referred. 9 

M. Guersent states that he has performed the operation one hundred 
and fifty times since 1834 ; the later operations having been much more 
successful than the earlier ones. In 1850 he operated upon forty chil- 
dren in private practice, and eleven recovered ; of twenty operated 
upon in the hospital, seven recovered. During 1851, of thirty-one ope- 
rations at the hospital, thirteen were successful. 10 

1 Transactions of Association of Physicians of Ireland, vol. iii. p. 170. 

2 Diseases of the Chest, p. 219. 3 Diseases of Children, p. 85. 

4 Diseases of Children, p. 309. 

5 American Journal of Med. Sciences, April, 1849, p. 307. 

« Jan. 6, 1847. 7 Brit. Record of Obst. Science, Feb. 1, 1848, p. 60. 

8 Med. Times and Gazette, May 21, 1853, p. 522. 

9 Condie, Diseases of Children, p. 309. 

10 M£m. de la Societe, de Chir. de Paris, vol. iii. 1852-3. Brit, and For. Rev., Ap. 
1854, p. 466. 



288 croup. 

The researches of M. Bretonneau revived the operation in France, 
and gave hopes of its being more successful. Out of fifty-five cases of 
different ages, he found the exudation reaching to the bronchial ramifi- 
cations in six or seven ; in one-third of the whole number it reached as 
far as the bifurcation, and in thirty or thirty-one, it terminated at dif- 
ferent parts of the trachea, so that it was inferred that it was possible 
to perform the operation below the seat of the disease, and that to 
these cases the most formidable of the objections would not apply. M. 
Fourquet mentions five successful operations out of seventeen, by M. 
Bretonneau, and strongly advocates the operation. It was performed 
on the child of Dr. Scoutetten, aged three weeks, on the third day of 
the disease, and under very unfavorable circumstances, and it recovered. 

M. Valleix found that out of a number of cases treated by medicine, 
about one-third recovered, and as many when the operation had been 
performed, and certainly, as he remarks, even one recovery ia a life 
saved, inasmuch as the operation is generally performed under most dis- 
couraging circumstances, and as a dernier ressort. 

Dr. Karl Weber has recently recorded two cases, one of which suc- 
ceeded. 1 

More recently, M. Trousseau has reported the result of the operation 
in 150 cases, of which thirty-nine recovered, and 111 died. He is, of 
course, favorable to the operation, which he advises as soon as we are 
sure that false membranes exist in the larynx. He prefers tracheotomy 
to laryngo-tracheotomy, for although the latter is the more simple and 
the more easily performed, by the former we get more probably below 
the disease, and the canula is more easily tolerated ; it occasions less 
irritation ; and, after all, he concludes that there is little danger from 
tracheotomy, as he has performed it 121 times, with only one mis- 
chance as far as the operation was concerned. He gives the following 
summary of the success of croup treated by tracheotomy. M. Bre- 
tonneau saved six out of twenty ; M. Trousseau saved twenty-seven out 
of 112 ; M. Leclerc, of Tours, succeeded in two cases ; M. Velpeau suc- 
ceeded in two out of ten ; M. Petit in three out of six. He mentions 
that there are also living in Paris about fifteen children saved in croup 
by tracheotomy, performed by Gerdy, Robert, Guersent, Jun., Boni- 
face, Depres, Blandin ; &c, but he is unable to communicate particu- 
lars. 2 

420. From the slight sketch I have given, the reader will perceive 
that the weight of authority, especially in Great Britain and America, 
is against the operation in croup, and also that the results of the cases 
in which it has been performed exhibit no very encouraging success. As 
an argument, this is not worth much, however, to those who regard the 
operation as a " dernier ressort," to be adopted in no case where there 
is hope from the ordinary method of treatment. 

The objections to the operation are principally these : — 

I. That the larynx is not mechanically closed by false membrane ; 
that in all cases, as Dr. Cheyne has remarked, there is sufficient space 

1 Henle's Zeitschrift, vol. iii. pt. 2, p. 8. 

2 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 379. 



croup. 289 

for the access of air ; that if the larynx be closed, it must be by spasm 
in addition to the exudation ; and that, therefore, to attempt relief by 
a mechanical operation would be superfluous, to say the least of it. 

II. That it is extremely difficult to say that exudation has taken 
place, and still more to fix the limits of it, and pronounce in any case 
that it has not extended below the larynx ; and yet upon this depends 
the utility of the operation, for, 

in. If the false membranes have extended below our incision, the 
operation, being purely mechanical, can afford no relief, but may seri- 
ously add to the clanger. 

iv. Bronchitis or pneumonia may exist at the time of the operation, 
or may very likely arise very soon after, and render it altogether useless. 

v. The operation itself is not without danger, nor quite so easy as 
has been stated, especially with young infants. In addition to hemor- 
rhage and escape of blood into the trachea, the patient may be attacked 
by prolonged syncope, asphyxia, or convulsions, as occurred in M. 
Trousseau's practice, and occasionally either of them may prove fatal. 

vi. That the risk of inflammation and other accidents after the ope- 
ration is very considerable, and materially diminishes its value. 

vn. That the results of the operation hitherto, although successful to 
a considerable extent, are not sufficient to justify our having recourse to 
it under ordinary circumstances. " If," says Mr. Porter, " it were 
possible to place a host of those cases in which bronchotomy had not 
proved serviceable, in array against those wherein it had seemed to be 
useful, it would scarcely be necessary to advance any further argument 
in proof of its uncertainty." 1 

421. Still Mr. Porter admits, very justly, that he cannot say that 
there are no cases of croup in which tracheotomy would be useful and 
proper ; the great difficulty is how to recognize them with sufficient ac- 
curacy. If it were possible to ascertain that false membranes had 
formed in the larynx without extending beyond it, that the lungs were 
free from disease, the constitution good, and no cerebral symptoms 
present, then, the dyspnoea being relieved, and the threatened asphyxia 
postponed, we might hope to gain time for the operation of other reme- 
dies ; for, as Trousseau remarks, tracheotomy is not a cure, but a means 
of gaining time for a cure. Mr. Porter has himself mentioned a case in 
which it might be employed: "But if the infant is, to all appearance, 
dead, and if the practitioner is called to him within any reasonable time, 
he should then, with the least possible delay, endeavor to inflate the 
lungs and restore animation by whatever means shall appear to be the 
speediest, and of these, perhaps the most preferable will be laryngo- 
tomy " 

422. This being the case, I shall mention a few of the peculiarities in 
the mode of performing the operation suggested by MM. Bretonneau 
and Trousseau. The trachea should be laid open freely, and as quickly 
as possible ; if we can avoid cutting through the veins it is desirable, 
but if we cannot, it is unnecessary to apply a ligature, as the bleeding 
will stop the moment the canula is introduced. Much time is thus saved, 

1 Surgical Pathology of the Larynx and Trachea, p. 64. 

19 



290 croup. 

and we escape the chances of phlebitis. When the trachea is opened, a 
dilator is to be introduced into the wound, the child placed upright, and 
time allowed for the establishment of respiration and the arrest of the 
hemorrhage; or a portion of one or two of the rings of the trachea 
may be removed which will render a canula unnecessary according to Mr. 
Lawrence's suggestion, or we may use the instrument recently invented, 
which saves time and the necessity for cutting the cartilages. If the 
child is in a state of asphyxia or syncope, cold water should be dashed 
in its face, and a feather introduced into the trachea, so as to excite in- 
spiratory action. In case of orthopnoea, a few drops of water may be 
thrown into the trachea, and that tube cleared of blood and false mem- 
brane by means of a small sponge fixed upon a slender stem of whale- 
bone. Generally speaking, the child will itself reject the blood or loose 
fluid matters which may be in the trachea, but it will require several 
light spongings to ged rid of the false membranes; and when this is 
done, if the respiration be fairly established, and the child be vigorous, 
we are advised to inject fifteen or twenty drops of a weak solution of 
nitrate of silver ; or if the larynx alone be affected with the disease, to 
apply a stronger solution to it by means of the sponge. 

M. Trousseau prefers the large curved canula of M. Bretonneau, or 
the bivalve canula of M. Gendrin. It is necessary to have it sufficiently 
long to allow for the subsequent swelling of the parts, and wide enough 
to allow for the expulsion of mucus. The canula should be withdrawn 
and cleansed whenever the air does not pass freely through it. At 
first the dilator will be necessary for its introduction, afterwards the 
wound remains open, and the replacement is easy. After the fourth 
or fifth day, if the case be going on favorably, we may allow the at- 
tempt to breathe through the larynx, as " an essential principle of tra- 
cheotomy is to withdraw the canula as soon as possible ;" and when 
the patient has been gradually accustomed to natural respiration, and 
it is performed with facility, the canula may be altogether withdrawn, 
and the wound closed. 

But the operation is only a part of the treatment, merely for the 
relief of the asphyxia, and will probably fail unless topical remedies be 
applied. Those recommended by Trousseau and Bretonneau are a 
strong solution of nitrate of silver applied with the sponge to the larynx, 
and a few drops of a much weaker solution injected into the trachea, 
four times the first day, three times the second and third, and once or 
twice the fourth day, followed by a little warm water. A few drops of 
water may be thrown into the trachea once or twice every hour, and if 
the breathing be embarrassed by mucus, the sponge must be lightly used 
after the injection of water. 

423. I shall conclude this account of the operation from M. Trousseau 
by quoting his propositions relative to the prognosis : — 

" 1. If the commencement of the attack date several days back, if, 
consequently, the disease has advanced slowly, whatever may be the 
-extent of the false membranes in the trachea or bronchi, the child will 
either recover, or, at any rate, live several days. 

" 2. But if the disease have been rapid, even though we ascertain, 



croup. 291 

at the moment of the operation, that the false membranes do not extend 
beyond the larynx, the patients die quickly. 

" 3. If, before the operation, the false membranes have invaded the 
nose, if they cover the surface of a blister, if the child be pale and 
somewhat puffed, -without having taken mercury or been bled, or if it 
have lost much blood, there is little chance of success from the opera- 
tion. 

" 4. If, before the operation, the pulse is moderately frequent, and 
if afterwards it is calm, we may hope. 

" 5. If, immediately after the operation, respiration becomes very 
rapid, and the child coughs but little or not at all, it is a bad sign. 

" 6. More boys than girls are cured. 

" 7. Children under two and above six years are easily cured. 

" 8. Caeteris paribus, the danger is in proportion to the extent of the 
false membranes. 

" 9. If the child have been subject to chronic catarrh, and if it had 
been suifering from cold some time before being attacked by croup, 
tracheotomy will be more likely to succeed. 

" 10. Even when the progress is favorable, very rapid respiration is 
a bad sign. 

" 11. The more rapid and more energetic the inflammation which 
attacks the wound, the better are the chances of cure ; a sudden sinking 
in of the wound is a fatal sign. 

" 12. There is nothing to fear so long as the respiration is noiseless, 
or when the sound is produced by the disturbance of the mucus ; but if 
the respiratory sound resembles the noise of a saw cutting a stone, death 
is certain. 

" 13. If pneumonia or pleurisy supervene, it is no ground for despair- 
ing of the patient. 

" 14. Agitation and sleeplessness are bad signs. 

" 15. If the wound be covered with false membranes ; if, after the 
removal of the canula, it remains a long time gaping ; if, when almost 
cicatrized, it reopens freely ; we may conclude that the child is in 
danger. 

" 16. The sooner the larynx becomes free after the operation, the 
sooner we can dispense with the canula, the more certain and rapid will 
be the cure. 

" 17. If croup have supervened upon measles, scarlatina, smallpox, 
or hooping-cough, although there is ordinarily no connection between 
those diseases and cynanche maligna, tracheotomy will not succeed. 

" 18. If, on the third day after the operation, the expectoration be- 
comes mucous and catarrhal, the infant will recover ; if, on the contrary, 
there is none, or it is serous, or like half-dried mucilage, the child will 
die. 

" 19. If the patients react violently against the injections of water 
or the sponging, we must not lose hope, how bad soever the other symp- 
toms may be. 

" 20. Children attacked by convulsions die, and they are the more 
liable to them in proportion to their youth, and to the quantity of blood 



292 ATELECTASIS PULMONUM. 

" 21. When, after the tenth day, the drink passes from the pharynx 
into the larynx and trachea, even though easily rejected, the patients 
most frequently die. 

" 22. Increase of the fever after the fourth day, agitation, collapse 
of the wound, and dryness of the trachea, rapidity of respiration, and 
frequency of cough, announce the commencement of pneumonia, which, 
at first lobular, becomes pseudo-lobular, and must be treated by the 
usual means, with the exception of blisters, which are apt to be covered 
with the false membranes." 1 

424. During the attack of croup the diet should be strictly antiphlo- 
gistic, but when the child shows indications of exhaustion, we may give 
light nourishing food, in any form of the disease. 

Cold water, whey, barley-water, &c, are pleasant drinks, and should 
be given quite cold. The temperature of the room should be moderate 
and agreeable, the air kept pure and fresh, and the bedclothes light 
yet warm. 

In favorable cases, when the child is convalescent, the clothing must 
be carefully arranged, to secure against cold. I should recommend that 
a light, thin flannel waistcoat be worn for some months. The child 
should go out only during the warm parts of the day, and carefully 
avoid damp or cold, and during the prevalence of east winds had better 
remain in the house. 

425. Prophylactic Treatment. — "When croup appears among the chil- 
dren of a fatuity, our attention should be directed to those not attacked, 
in order to anticipate and prevent such a seizure ; and a patient recover- 
ing from the disease must be watched subsequently with more than 
ordinary care. All predisposing and exciting causes should be removed 
or neutralized, if possible. If the climate or locality are unfavorable, 
the children should be removed, at least for a time, and if that be im- 
possible, other suitable precautions must be taken. Flannel should be 
worn to guard against vicissitudes of temperature or cold winds. The 
cold or shower bath may be used, followed by smart friction, so as to 
insure reaction. The bowels should be kept free, and the slightest 
cough or cold attended to. 

If an attack be threatened, an emetic, followed by expectorants, 
warm baths, purgatives, and counter-irritation, should be instantly 
given. 



CHAPTER V. 

ATELECTASIS PULMONUM. 



I. This term has been given to a condition of the lungs, or a portion 
of them, which is of comparatively recent observation, and the precise 
pathological value of which is far from being settled as yet. 

1 Rilliet and Barthez, Mai. des Enfans, toI. i. p. 380. 



ATELECTASIS PULMONUM. 293 

We may take as the type of this condition, the lungs of a foetus who 
lias not breathed, although the extent varies very much, and according 
to the extent so do the symptoms. 

This state, to which the names atelectasis, atelectasia, apneumatosis, 
etat foetal, &c, have been given, may be observed immediately after 
birth, or at a later period; the former is evidently congenital, the latter 
acquired. I feel no doubt as to the occurrence of such an acquired dis- 
ease, any more than of its being also congenital, although I may not 
quite agree with the interpretation that has been given of it. 

2. Let us first examine into the form of the disease as we see it in 
infants of a few days old, as it has been described by MM. Joerg, 1 
Hasse, 2 &c, and thus we shall be better prepared to appreciate it in 
older children. 

I. 8. Symptoms. — We find the atelectasis of new-born infants charac- 
terized by a feeble and incomplete respiration, which is occasionally in- 
termitting. Instead of the loud hearty cry, the child wails weakly and 
complainingly from want of breath. It seems to have great difficulty 
in sucking, and if the chest be stripped so as to be observed naked, it 
has scarcely the usual rounded appearance, and its movements are 
limited, or apparently inverted, the sides of the chest being flattened 
rather than expanded. 

The surface is cold and more or less livid from the imperfect aeration 
of the blood ; the pulse is weak and languid. If the amount of imper- 
meable lung be not so great as to be inconsistent with a prolongation 
of life, it is sure to influence and impair the nutrition, the infant be- 
comes weak, delicate and emaciated. 

Dr. Rees mentions that such patients are obnoxious to attacks of 
laryngismus stridulus, by one of which the infant is frequently carried off. 

When the atelectasis is of moderate extent, it may terminate in par- 
tial or complete recovery, but when at all extensive it usually ends 
fatally.- In some cases when great efforts are required for respiration, 
Jberg states that congestion or inflammation of the lungs may be pro- 
duced: in this, however, Hasse differs from him, and considers that in- 
flammation is neither necessary nor even frequently the consequence of 
atelectasis, for that the part of the lung in this condition is passive to 
other morbid processes, especially to inflammation, as he has seen these 
parts remain unaltered in the midst of surrounding hepatization. 

From recent researches, we have reason to believe that this state of 
the lungs has an important relation to oedema of the cellular tissue, of 
which I shall speak hereafter. 

4. Now the state of the lungs which gives rise to these symptoms is 
simply that a portion of them remains in the condition in which it was 
before birth, undilated and impervious to air. Medico-legal researches 
have shown long ago, that the entire foetal lung is not at once inflated, 
but the small portion thus temporarily impervious gradually diminishes, 
and does not interfere with the well-being of the infant. If, however, 
a larger portion be undilated and remain permanently so, then we have 
the disease in question produced. 

1 Die Fcetuslunge in neuoorneD kinder. 

2 Pathological Anatomy, p. 248. Sydenham Society. 



294 ATELECTASIS PULMONUM. 

That portion of the lung in a state of atelectasia, seldom so much as 
an entire lobe, appears condensed; it is depressed below the level of the 
neighboring or surrounding parts, of a dark reel or violet color, without 
crepitation, and when divided by the knife, no air can be expressed. 
The cut surface is red and smooth, from which, when squeezed, a slightly 
sanguineous serum without air bubbles exudes, and the affected part 
sinks absolutely in water. The tissue feels rather harder than other 
parts, but less tenacious. " The diseased patches," says Hasse, " display 
a brown red, or rather a bluish red color, which is more intense if the 
whole lobule is uniformly unexpanded, in which case it is marked off by 
a sharp contour from the surrounding pale-red healthy substance. When, 
on the other hand, scattered cells within such a lobule become inflated, 
the violet color is interrupted here and there, and passes by a gradual 
transition, and without any distinct boundary, into the natural shade. 1 
The inferior and posterior portions of either or both lungs may be 
affected, but most frequently those of the right lung. When atelectatic 
infants die a day or two after birth, it is generally possible to dilate 
artificially the undeveloped part. The depressed lobule is then seen to 
rise gradually to the level of the rest, and to assume the color, permea- 
bility, and the characters of sound lung, but this does not appear to be 
always possible when it has remained for weeks or months in a state of 
atelectasis. In infants dying from this disease, both Joerg and Hasse 
found the foramen ovale invariably open. 

So far then as our investigations have as yet gone, it would appear 
that this state of the lung in new-born infants, is not the result of in- 
flammation ; that it is not necessarily connected in any way with inflam- 
matory action in the lungs ; nay, that it is not, properly speaking, a dis- 
ease at all, but merely an arrest of physiological development ; there 
is nothing new or morbid in this part of the lung, but merely the per- 
sistence of the old intra-uterine condition. 

5. Causes. — There is great obscurity about the causes of this affection ; 
in many cases we cannot account for it all ; in others, it may perhaps be 
owing to defective nervous energy, in consequence of compression of 
the head during its passage through the pelvis, inducing a degree of 
asphyxia. 

6. Treatment. — It is not improbable that this condition may be pre- 
vented if we are careful to induce full inspiration when the child is 
born, so as to establish respiration completely before the funis is divided. 
The impression of cold, and the unceremonious handling, washing, &c, 
generally achieve this, but we ought to see that it is secured ; and if 
we find the respiration feeble, and the cry unusually weak, the mouth 
being clear of mucous, the infant should be stimulated by slight taps, 
sprinkling of cold water, frictions to the back, warm baths, &c, until 
we are satisfied with the action of the lungs, or that these remedies have 
failed altogether. 

Joerg recommends repeated enemata and emetics ; the former can do 
no harm, and may do good, but I should fear a frequent repetition of 
the former. 

A warm equable temperature is necessary, and the infant should not 

1 Pathological Anatomy, p. 249. 



ATELECTASIS PULMONUM. 295 

be clothed less warmly than usual, and at the time of dressing and 
undressing, the back and chest should be well rubbed with the warm 
hand. 

II. 7. The acquired form of atelectasis is characterized by a dry bark- 
. ing cough, very distressing, which may continue for a considerable time, 
and recur after an uncertain interval of rest ; it is generally worse at 
night than in the daytime. There is also a certain amount of dyspnoea 
varying according to the extent of the solidified portions of the lungs, 
and it possesses this peculiarity according to Dr. Rees, that it is shown 
" first in the rapidity, and secondly, in the unequal lengths of the in- 
spiratory and expiratory efforts, the former being much the longer ; 
moreover, owing to the persistence of the difficulty, it becomes habitual 
to the child, so that you find it cheerful, and taking notice, when the 
quickness of breathing is to the observer really distressing, and would 
be taken by any one unconversant with the nature of the case to denote 
active inflammation." 1 

The action of the heart is naturally much increased both in frequency 
and force, so as after some time to indicate that enlargement has taken 
place, and this violent action is occasionally accompanied by hemor- 
rhage from the nose, rectum, &c, which appears to afford temporary re- 
lief. 

But the most striking symptom of all is the altered movement of the 
ribs in respiration, which resembles the peculiar motion which every 
one must have observed in an infant at birth before respiration is com- 
pletely established, viz : during inspiration the ribs laterally are drawn 
rather inwards and backwards towards the mesial line, protruding the 
sternum slightly instead of distending outwards, as in ordinary inspira- 
tion, the result of which is rather a diminution than an increase in the 
cavity of the chest. This, which can only be detected when the chest 
is uncovered, will serve to impress upon my junior readers the necessity 
of a thorough and minute examination of the chest of infants and chil- 
dren whenever the lungs appear to be affected. 

If the atelectasis be extensive, of course there will be dulness on per- 
cussion over the diseased portion, and a deficiency of respiratory mur- 
mur, with perhaps bronchial respiration. 

As in new-born infants in whom this state continues long, we find 
the power of nutrition greatly impaired, the child becomes emaciated, 
but not so much so as in the former class of cases according to Dr. 
Rees, and it is seen chiefly in the limbs, the abdomen always becoming 
tumefied. The skin acquires a dusky color, owing probably to the im- 
pediment offered to the return of the blood and its imperfect oxygena- 
tion. The general symptoms of inflammation of the lungs are entirely 
absent. 

Lastly, Dr. Rees has stated a result of long continued atelectasis, 
which appears to me to require somewhat more evidence than we have 
at present. He believes that in adaptation to the state of the lungs 
the form of the chest becomes gradually changed. " The direction of 
the deformity will depend upon the original constitution of the patient. 

1 Atelectasis Pulmonum, p. 8. 



298 ATELECTASIS PULMONUM. 

If a strumous diathesis be present, strumous or rickety malformation 
of the chest will result. The bones themselves will yield beneath the 
arms, where a hollow will occur, narrowing the cavity in that direction, 
while the front projects unnaturally forwards. The common form of 
rickety chest is, I believe, usually the consequence of atelectasis of the 
lung, and this explains a difference not readily accounted for ; namely, 
why in one case, with considerable rickety deformity of the extremities, 
there is a fully expanded and well-formed chest, while in another, with 
the limbs straight, the altered shape cf the chest is so considerable ; it 
is because in the latter case the lungs have previously become shrunken, 
owing to a vitiated atmosphere or other depressing cause, atelectasis of 
the lungs has taken place, and the walls of the chest are forced in- 
wards to adapt them to the state of the respiratory organs." 1 

Now, without denying that this may be the case in some instances, I 
cannot think that it is the ordinary way in which pigeon breast is pro- 
duced. If a collapsed state of the lung alone involved such an adapta- 
tion of the ribs, we should surely see it, as Dr. Corrigan suggested to 
me, in pleuritis, in which the chest contracts but the deformity in ques- 
tion is not produced. We can understand, however, that if a rickety dis- 
position of the bones of the ribs exists, together with atelectasis, that 
the atmospheric pressure externally not being counteracted by expan- 
sion of the lung, the result of these two conditions may be the flatten- 
ing of the ribs, and protrusion of the sternum ; or, the pressure of the 
atmosphere alone with the ribs in this condition may, and often does, 
produce this deformity, as Dr. Corrigan has shown. 2 

8. Pathology. — The condition of the affected portion of the lung does 
not differ materially from that which I have already described. It is 
of denser texture, of a darker color, and depressed somewhat below the 
level of the neighboring parts. The pleura, according to Fricdleben, 
is somewhat thickened, and can be peeled off the affected parts. 

But the most important fact is that by inflation those parts can be 
raised to the level and made to assume the appearance of the healthy 

lun s- 

The deformity of the chest will be apparent, if it exist, as well as the 
tumid abdomen, with the enlarged venous trunks both external and 
internal. 

The heart is generally hypertrophied, but chiefly the cavities of the 
right side, if the disease has existed for some time. 

9. So much for the post-mortem appearances. There are, however, 
two important pathological questions, about one of which a good deal 
has been written latterly, but which can hardly be answered satisfac- 
torily at present, upon which I must say a few words. 

1. Is atelectasis ever an acquired disease, or is it merely that the 
foetal condition of the lung has remained unchanged from birth until 
the age at which it is discovered ? 

Friedleben takes the latter view, and whatever he writes is entitled 
to respect. He founds his opinion upon the anatomical characters, 

1 Atelectasis Pulnionuni, p. 11. 

2 See Dr. Corrigan' s Lecture, Dublin Kosp. Gazette, Ap. 1, 1845, p. 47. 



ATELECTASIS PULMONUM. 297 

which undoubtedly resemble as closely as possible the foetal lung, 1 and 
upon the physiological impossibility that the lung could lose its power 
of expansion without mechanical cause ; " but this appears to me a 
petitio principii," the supposition being that it does so ; and, surely, if 
probabilities are to have any weight, it is at least as unlikely that a 
portion of the lung not affected by disease or mechanical impediment, 
should remain for years after birth unchanged. 

The great authority of Dr. West is decidedly in favor of atelectasis 
occurring at a period subsequent to birth, "so that lungs once perme- 
able to air may cease to admit it, and death at length occur from 
apnoea, without any serious structural change having taken place in the 
organs of respiration." 

Dr. G. A. Rees, in his pamphlet, has given seven cases in which he 
detected it in children from two months to two years old, and he enter- 
tains no doubt of its being an acquired disease. 

If I had any doubt in my own mind, the experience and observations 
of Drs. Baly and Gairdner 2 would have removed it, as they have 
recorded a precisely similar condition, the effect of disease, in adults 
of various ages. 

2. Is atelectasis identical with that disease which has been described 
as lobular pneumonia, or with the carnification which we meet with in 
lungs affected by pneumonia ? 

In the chapter on pneumonia, I have shown that this is pretty much 
the view taken by both Legendre and Bailey, founded mainly upon the 
fact that in some, but by no means in all cases, they succeeded in 
inflating the lobules. This opinion has been still further carried out by 
M. Fuchs. 

Dr. West conceives that most if not all the cases of so called lobular 
pneumonia, and especially of that stage which has been termed carni- 
fication, were, in truth, examples of atelectasis produced by an occlu- 
sion of the pulmonary vesicles. "Nothing," he says, " can show more 
forcibly the influence of a name than the fact that this condition of the 
lungs should have been described by all writers as lobular pneumonia, 
and that its symptoms should have been attributed to inflammation, 
while yet it was evident from the concurrent testimony of every one 
that neither in its progress nor in its results was it similar to inflamma- 
tion in the adult, much less identical with it." 3 

An attentive consideration of the arguments and evidence adduced, 
whilst it has satisfied me that atelectasis has frequently been mistaken 
for lobular pneumonia, has not, I must confess, convinced me that the 
two diseases are identical. As yet, I am not prepared to deny the dis- 
tinct existence of lobular pneumonia any more than that of atelectasis, 
unless more extended observation shall afford a greater mass of evi- 
dence than we at present possess. This seems to be as nearly as possi- 
ble the opinion of M. Hasse, who thus draws the distinction between 
the post-moriem appearances of atelectasis and pneumonia. "In atelec- 
tasis, the coloring of the diseased portions of lung always approaches 

1 Archiv. fur Physiolog. Heilkunde, 1847. 

2 Edinburgh Monthly Journal, Nov. 1850. 

3 Diseases of Infancy and Childhood, p. 159. 



298 ATELECTASIS PULMONUM. 

more to a violet, their exterior appearing smooth and glistening, so as 
to contrast with the dull brown red surface of inflammation. In in- 
flammation, again, the diseased portions are preternaturally distended, 
whilst in atelectasis they are collapsed, and inferior even to the healthy 
texture in volume, but susceptible, provided the disease has not lasted 
too long, of artificial inflammation, and capable through its means of 
acquiring a perfectly natural appearance. In inflammation the pulmo- 
nary texture is softened; in atelectasis it is hard, and the cut surface 
is not granular, but smooth. "Where no complication exists, the anatomi- 
cal characters of a first or third stage of pneumonia are not discover- 
able in or near the diseased patch : in short, we have nothing like pneu- 
monia except the solid non-crepitant mass which has been confounded 
with the second stage of that disease, viz : with red hepatization." 1 

He adds, that "unequivocal cases of infantile pneumonia, whether lo- 
bar or lobular, such as I have myself examined, and such as Kewisch has 
published, afford, on the other hand, the strongest negative grounds for 
establishing atelectasis as a distinct form." 

From the evidence adduced, I think I may draw the following con- 
clusions : — 

1. That in certain new-born infants a portion or portions of the lung 
remain undilated or impermeable to air, and that these give rise to cer- 
tain symptoms and signs, and involve certain consequences already enu- 
merated. That the anatomical characteristics of these portions of the 
lungs are their being solid, free from air, of less proportionate bulk, 
capable of being inflated, and after inflation of assuming their natural 
character. 

2. That a similar disease may be acquired during childhood present- 
ing analogous signs and similar anatomical characters. 

3. That this condition may be, and probably has often been, mis- 
taken for lobular pneumonia, especially in young infants. That patho- 
logical condition which has been termed " carnification," has certainly 
a very close resemblance to the condition of the lung in atelectasis, and 
I should not be prepared to deny that such cases may really be exam- 
ples of the latter disease. 

4. But I cannot at present agree with the opinion that all which has 
been regarded as lobular pneumonia, is really but atelectasis superin- 
duced by a vascular congestion, closing the air-cells, or by an obstruc- 
tion in the air-tubes. 

5. It does not seem impossible that this disease, although distinct 
from pneumonia, may result from it, or from an attack of bronchitis, 
as Dr. Rees believes, and as Dr. Gairdner's researches have proved, in 
the case of adults. 

10. Diagnosis. — The most important diagnostic sign of atelectasis is 
the altered movements of the ribs, which only occurs in one other disease, 
viz: occasionally in croup. In the latter disease it has been noted by 
Dr. Rees and Sibson, but the accompanying symptoms are too marked 
for any one to confound the two diseases. 

Dulness on percussion, with the absence of either respiratory murmur 

1 Pathological Anatomy, p. 252. 



ATELECTASIS PULMONUM. 299 

or crepitation, may perhaps enable us to distinguish it from pneumonia, 
but there may be doubtful cases. 

The progressive emaciation accompanied by the pulmonary symptoms 
may excite suspicions of phthisis, but a careful examination will gene- 
rally lead us to a correct conclusion. 

11. Prognosis. — If timely measures be adopted, this disease is cura- 
ble, and even when they are neglected or fail, if the child survive for 
a time, the constitution becomes familiarized to the state of the lungs, 
and certain adaptations occur which allow of the child growing and 
thriving. 

In other cases, however, the secondary effects are more serious, the 
child becomes more and more emaciated and reduced in strength, the 
cough is very distressing, and he dies at length of exhaustion. 

12. Treatment. — Very active treatment is evidently quite unsuitable 
to these cases, and so far as we yet know, the number of remedial agents 
is but small. 

The first object should be to place the child in suitable hygienic cir- 
cumstances — to secure a plentiful supply of pure air, warm clothing and 
suitable food, as to a deficiency in these requisites we may frequently 
trace the origin of the disease. 

The diet should be good, but not excessive in quantity ; meat once a 
day, with milk or very weak tea, but neither vegetables, fruit, nor pastry, 
on account of the disordered state of the digestive organs, as evidenced 
by the tumid belly. 

Emetics occasionally seem to be of use as well as stimulating expec- 
torants, such as the decoction of senega with ammonia. 

A very principal part of the treatment must be directed to the skin 
and kidneys. Dr. Rees prefers a combination of ipecacuanha with nitre, 
hyoscyamus, and sulphate of magnesia, so as to act as a gentle purgative, 
as well as a diuretic. 

A mild mercurial, the hyd. c. creta, for instance, may be given occa- 
sionally alone, or in combination with a purgative, as the bowels are 
generally confined. 

External irritation, by rubefacients or blisters, may be tried, and it 
appears to me probable, that electro-galvanism might be of use, but I 
am not aware of its having been tried. 

In accordance with his views, as to the production of deformity, Dr. 
G. A. Rees insists upon the patient observing a recumbent position, 
lying on its back on a firm unyielding surface: "The position seems to 
antagonize, to the small extent we are able, the altered movement, and 
by keeping the spine supported and extended, renders more tardy the 
projection of the column, thus giving the best chance for the extended 
lung again to expand." 



300 BRONCHITIS. 



CHAPTER VI. 

BRONCHITIS. 

426. Bronchitis, or bronchial catarrh, is the term applied to inflam- 
mation of the mucous membrane of the bronchial tubes, accompanied 
with increased secretion ; and those two elements, the inflammation and 
the secretion, not being necessarily in exact proportion to each other, 
has led writers to regard the disease either as a simple inflammation 
or as a catarrh, according to the predominance of either, and occa- 
sioned their estimating the disease as more simple than it is in fact. 
Following the example of M. Barrier, I shall use either term to ex- 
press the disease, without limiting my meaning to the strict pathologi- 
cal definition of either. 

In one form or other, it is undoubtedly one of the most frequent dis- 
eases of infancy and childhood. From the moment of birth, indeed, to 
extreme old age, none are altogether exempt from its attacks ; but it 
is at the extremes of life that it is more severely felt, and more serious 
in its consequences. 

427. Bronchitis may be primary or secondary, simple or complicated, 
general or partial, acute or chronic, and these circumstances will require 
serious consideration in our estimate of the disease, and in determin- 
ing the treatment. Let us first speak of primary bronchitis, which 
I shall divide into acute and chronic ; and afterwards of secondary pul- 
monary catarrh. 

I. Acute Bronchitis. — The ordinary form of acute bronchitis com- 
mences generally with a chilliness over the whole body ; the child com- 
plains of cold, and objects to quit the fire ; this is followed by more 
or less of feverishness. There is a certain amount of cough from the 
commencement ; sometimes it is slight, at others severe, very rarely 
in paroxysms ; it may be moist or dry, but it is rarely a hoarse cough. 
At first the child seems to suffer pain from the cough, and, if old 
enough, complains of soreness on coughing, which disappears as the 
disease advances. In the commencement there is no secretion of mucus, 
which gives a hard character to the cough, but in a day or two there is 
a more or less profuse secretion, which, whilst it relieves the distress in 
one respect, may increase it in another by impeding respiration, espe- 
cially with young infants. 

The breathing is generally accelerated, but the amount varies ac- 
cording to the intensity of the disease. So long as the attack is con- 
fined to the larger bronchial tubes, and if the child be tolerably healthy, 
the respiration is not much hurried; it ranges from 28 to 40 per minute, 
nor is there much increase of respiratory effort ; but when , the smaller 
tubes are invaded, it is both accelerated and impeded, requiring rapid 



BRONCHITIS. 301 

and energetic muscular effort. When the mucous secretion is estab- 
lished, and in proportion to its abundance, there is a wheezing and 
rattling in the chest very audible at some distance. 

In proportion to the cough and disturbance of the respiration will in 
general be the state of the pulse. In slight and partial attacks it may 
be but little quickened, but when the disease is general, and the respi- 
ration much embarrassed, the pulse will be found very rapid, and the 
fever considerable. 

The countenance generally expresses distress ; at the beginning it is 
flushed, but in a more advanced stage, and in proportion to the impedi- 
ment to respiration, it acquires a bluish tinge, as the consequence of 
the imperfect aeration of the blood. 

428. The physical signs are simple and easily recognized. On per- 
cussion, the chest yields a clear sound, if the disease be uncomplicated ; 
but in severe cases we find here and there a certain amount of dulness, 
which is probably owing to a partial complication with pneumonia. 

If the ear or the stethoscope be applied to the chest, we shall find 
the sonorous, mucous, or sibilant rales pretty general, the former espe- 
cially before the mucus is freely secreted, the latter afterwards. Some- 
times the respiratory murmur is completely and permanently masked by 
them ; in other cases they are more partial and temporary, and we can 
still hear the rapid respiratory murmur. In a few cases there is here 
and there a moist sub-crepitant rale audible. 

When the attack is slight, the appetite will be but little impaired, 
digestion will take place satisfactorily, and the bowels continue regular ; 
but when the fever is considerable, the appetite is lost, there is occa- 
sionally vomiting brought on by the cough, and the bowels will be more 
or less disturbed. 

429. Thus, as characteristic of the attack, we have cough, hurried 
respiration, perhaps dyspnoea, mucous secretion, and fever ; and these 
symptoms generally continue stationary for a few days ; then, in favora- 
ble cases, the fever gradually subsides, the respiration becomes more 
tranquil, the cough softer and less distressing, and by degrees the child 
becomes convalescent in the course of a week or two. 

This, however, must be considered a favorable case ; in many in- 
stances, the disease, instead of diminishing, assumes a more aggravated 
form ; it may either be complicated with pneumonia, or, extending to 
the capillary tubes, it may assume the characters of suffocative catarrh, 
which I shall describe immediately. In either case the cough becomes 
more troublesome, the respiration more hurried, the fever more intense, 
and the general distress and constitutional disturbance more severe. 
Auscultation will generally reveal the form which the disease has as- 
sumed, and, as we might expect, the general symptoms will also indicate 
the altered character of the disease. 

The result is much more doubtful than in the first cases ; they gene- 
rally recover, but when thus aggravated, if the child is much reduced 
already, and the attack very severe, the case may terminate unfavora- 
bly- 

430. The other modification of acute bronchitis to which I have 
alluded, and which has been called suffocative catarrh, capillary Iron- 



302 BRONCHITIS. 

c'hitis, catarrhal fever, is a more severe and more dangerous form of 
disease. It is not so common as the other forms of bronchitis ; Rilliet 
and Barthez met with but six cases of it as a primary affection, and 
three as a secondary. However, in certain epidemics of bronchitis it 
is much more frequent, as I have observed latterly in this city. 

As I have already mentioned, it may grow out of or be grafted upon 
the former slighter catarrh, or it may assume from the commencement 
its peculiar characteristics. In most cases, the general symptoms pre- 
cede the local, or at least their greater severity occasions them to oc- 
cupy most of our attention. 

The fever is intense ; the pulse rapid and full ; the skin is hot and 
dry, with occasional chills ; the face is flushed ; there is great thirst ; 
the tongue is white and coated, and there is no appetite. 

The respiration becomes rapid, not exactly difficult at first, but hur- 
ried ; it afterwards becomes difficult, with wheezing, and requiring great 
muscular effort. The cough, which either did not exist at first, or was 
too slight to attract much notice, is now developed or increased, for 
some time dry, and occurring in a kind of paroxysm or kink ; it causes 
great distress, and greatly increases the soreness or pain in the chest of 
which the child complains. 

At first there is no expectoration ; then we have a whitish or yellowish 
mucus, sometimes muco-puriform in its character, and, very rarely, with 
portions of lymph. 

431. The physical signs do not differ much from those in the ordi- 
nary and slighter forms of disease. The chest is generally clear on 
percussion, with the exception, perhaps, of some spots of small extent 
towards the base of the lungs. 

The respiratory murmur is entirely masked by the sibilant and mu- 
cous rales, which are heard over the whole lung, mixed, in some parts, 
with a moist crepitus. The wheezing is audible at some distance from 
the patient. 

432. These symptoms may all be observed very soon after the com- 
mencement of the disease, and every hour they seem to increase. The 
respiration becomes more hurried and embarrassed, and at length un- 
equal, irregular, and panting, with great oppression, and strong muscu- 
lar efforts, great heaving of the chest, and rapid action of the alas nasi. 
The face is pale or livid, especially after coughing, the lips purple, and 
the expression of the countenance that of intense anxiety and distress. 

The patient lies on his back, or requires to be raised into a sitting 
posture, according to the amount of distress in breathing. 

The mucous rales in the chest increase according to the abundance 
of the mucus secreted, which is occasionally so excessive as to threaten 
suffocation. 

The pulse becomes quicker, but smaller, weaker, and unequal, some- 
times, towards the end, irregular. 

If the disease be not quickly terminated, we may sometimes observe 
occasional remissions, followed by a return of all the symptoms. 

In unfavorable cases, the disease rapidly gains ground, the symptoms 
become aggravated, the cough most distressing and painful, the respira- 
tion amazingly rapid and difficult, the pulse very quick, irregular, and 



BRONCHITIS. 303 

almost imperceptible, the features changed, and expressive of agony, 
the face livid, and covered with profuse perspiration, and at length a 
kind of convulsive agitation or stupor terminates in death. 

I have remarked that in children of three years old and upwards, 
the disease may terminate in pneumonia, but in young infants more 
frequently in profuse fluid effusions into the bronchial tubes and cells, 
producing asphyxia. 

"In some cases," Dr. Watson observes, "in young patients in whom 
bronchitis is idiopathic, and not engrafted on any other disease of the 
chest, in whom the disorder had not appeared severe, extreme difficulty 
of breathing will sometimes most unexpectedly arise, and rapidly termi- 
nate in the extinction of life. This is attributed to the permanent ob- 
struction or plugging up of one of the bronchi. The slightest attack 
of bronchitis may, in this way, be suddenly transformed into a most 
serious and quickly fatal malady." 

433. The course of the disease is often very rapid. Rilliet and 
Barthez knew it terminate in three days. M. Fauvel found the dura- 
tion of the confirmed attack from six to eight days, although it may last 
much longer, even twenty or thirty days. 

But the attack does not always prove fatal ; under judicious treat- 
ment, at an early period, the disease may be checked, the fever then 
gradually diminishes, the dyspnoea and hurried breathing become calmer 
by degrees, the cough less frequent and distressing, and the child slowly 
recovers. 

434. The description I have just given is that of ordinary suffoca- 
tive catarrh, but in practice we find considerable modifications. Dr. 
Parrish, of Philadelphia, has described one which is worth noticing i 1 
" This modification of the disease commences with a cough, and the 
breathing soon becomes laborious and wheezing ; the face is very pale, 
and the whole surface cold, though generally soft and moist. The coun- 
tenance acquires a peculiar expression of distress and anxiety, and in 
some cases the cheeks become very cold, even when the other parts of 
the surface are of a natural temperature. The stomach and bowels are 
generally inactive, and the urine is small in quantity, but, so far as I 
have observed, of a natural and healthy color. After the disease has 
continued for some time, a cold perspiration breaks out on the face and 
neck. The cough is at first dry, attended with a wheezing sound in the 
chest, but towards the termination of the complaint it frequently be- 
comes hurried and rattling. The pulse, in violent cases, becomes very 
small and rapid, and the tendency to sinking is, in all instances, very 
obvious. There is constantly much difficulty of breathing, but at times 
the oppression becomes so great as to resemble a violent attack of 
asthma. Occasionally considerable remissions occur for a short period, 
during which the pulse will become fuller and slower, and the counte- 
nance brighter and more calm. When the disease is tending to a fatal 
termination, the patient becomes drowsy, insensible, and comatose, and 
death takes place by suffocation in a paroxysm of convulsions." 2 

1 North Amer. Med. and Surg. Journ., vol. i. p. 24. 

2 Eberle on Disecises of Children, p. 822. 



301 BRONCHITIS. 

435. Dr. Eberle lias described an epidemic which occurred in the 
eastern states of America in 1824, which he calls catarrhal fever, and 
which has very much the appearance of modified capillary bronchitis. 
"The disease began with a slight feeling of distress, and with a dis- 
tinctly formed chill. The hands and feet became cold, the whole surface 
of the body pale and contracted, and the patient appears languid and 
drowsy. This state of depression frequently continues for a whole day 
before the febrile action is fully developed. In many instances, how- 
ever, the fever supervenes in a very short time after the first feeling of 
indisposition. The patient complains of aching pain in the extremities 
and back, the pulse becomes frequent, somewhat tense, and generally 
full, the cheeks flushed, the eyes suffused with tears, and a thin, trans- 
parent fluid usually issues from the nose, attended, at the commence- 
ment, with frequent sneezing. The skin is dry and husky, though 
seldom much above the natural temperature. The bowels are torpid, 
and the urine scanty and high colored^ and in many instances the alvine 
evacuations, during the first few days, manifest a deficiency of secre- 
tion, and sometimes an entire absence of bile. In some cases cough, 
with slight hoarseness, is one of the earliest symptoms ; more frequently, 
however, the cough does not come on until the fever is fully developed, 
and often not until the disease has continued for two or three days. 
The breathing is not often much oppressed in the early periods of the 
disease, though frequently attended with a considerable rattling in the 
trachea. In severe cases, however, respiration is frequently difficult 
and wheezing, almost as soon as the fever is developed, owing to the 
abundant secretion of mucus into the air cells. This is most apt to be 
the case in infants, who, from not making any efforts to free the lungs 
by expectoration, suffer the bronchial secretions to accumulate in the air- 
passages." "In the ordinary form and course of the disease the expec- 
toration becomes very abundant after the fever has continued for three 
or four days ; and as the copious secretion of mucus keeps up a con- 
stant irritation of the bronchia, the cough usually becomes very fre- 
quent as the disease advances." 1 

436. The most marked distinction between the symptoms of ordinary 
bronchitis and the suffocative catarrh or capillary bronchitis, consists in 
the greater amount of fever in the latter cases, the occurrence of de- 
pression, almost amounting to collapse, the hurried, wheezing, and diffi- 
cult respiration, the cough being more frequent, and occurring in par- 
oxysms or kinks, and the more imperfect aeration of the blood, evidenced 
by the tumid and livid features, cold, pallid surface, &c. 

437. II. Chronic Bronchitis. — The chronic bronchitis of infants and 
children is generally the sequence of an acute attack of the ordinary 
disease, or of suffocative catarrh, the symptoms of which lose their 
acuteness, and in a great measure their severity. There is little or no 
fever during the day. The cough is soft, moist, and seldom occurs in 
kinks ; it is still distressing, however, and in some cases particularly so 
at night, or when lying down. The respiration is natural, with occa- 
sional paroxysms of dyspnoea. On applying the stethoscope, we find 

1 Diseases of Children, p. 318. 



BRONCHITIS. 305 

mucous rales mixed with a loud sound, as in dilated bronchial tubes, 
and the chest is clear on percussion. 

The pulse is quick, weak, and small, with some exacerbation in the 
evening, and occasional night-sweats. Considerable emaciation, also, is 
the result of the attack. The face is pale, and the eyes hollow ; the 
lips are bluish and sometimes cracked or ulcerated ; the edges of the 
nares are also sore, and kept so by the child picking them. 

The strength is very much diminished, the appetite deteriorated or 
lost, and in bad cases there is colliquative diarrhoea. 

438. The aspect of cases so severe as these is really that of phthisis, 
and in fact they may run on into that disease. 

MM. Rilliet and Barthez observe that " chronic bronchitis, simulating 
phthisis, may present itself under a still more unusual form, and last 
longer. The disease is then accompanied with fits of suffocation, fol- 
lowed by the rejection, sometimes, of a large quantity of pus, sometimes 
of tubes apparently pseudo-membranous, with the general symptoms 
already mentioned. Thus, in a case communicated to us by M. Legendre, 
the child, who was seven years and a half old, commenced, at the age of 
three and a half or four years, to reject, after fits of coughing, a con- 
siderable quantity of matter two or three times a day. There was 
constantly difficulty of breathing, fever in the evening, and night sweats. 
There was dulness on the left side posteriorly, and in that spot cavern- 
ous respiration, with mucous rales. The child had all the characters of 
phthisis. The fever increased, and the emaciative diarrhoea came on ; 
then gangrene of the mouth, which, added to the other disease, ended 
in death. The disease lasted near four years. It was ascertained by 
a post-mortem examination that the child had suffered from chronic 
bronchitis, with considerable dilatation of the bronchial tubes." 1 

The disease ordinarily lasts from thirty to forty days, and may then 
terminate fatally ; or, under the influence of judicious treatment, the 
disease may yield, the symptoms diminish, and the child regain its 
health gradually. 

439. Pathology. — There is some difficulty in ascertaining the pre- 
sence of inflammation in the smaller bronchial tubes, because their 
mucous membrane, being very thin, shows the color of the subjacent 
tissue ; and because, as M. Fauvel observes, the mucous membrane has 
this resemblance to serous membranes, that the redness disappears 
immediately after death. 

In slight cases of acute bronchitis, limited to the trachea and large 
tubes, the mucous membrane will be found red and inflamed, generally 
or in patches, with more or less abundant secretion. 

If the attack involve the middle bronchial tubes, we shall find the 
redness and abundant secretion, with dilatation of the tubes, in propor- 
tion as the disease has been of long standing. 

In the capillary bronchitis, the extremities of the tubes are closed, 
partly by the swollen state of the mucous membrane and partly by the 
accumulation of puriform secretion, notwithstanding the considerable 
dilatation which takes place in a few days. Not unfrequently, in this 

1 Mai. des Enfans, vol. i. p. 43. 

20 



306 BRONCHITIS. 

form of the disease, we find evidence of lobular pneumonia. Chronic 
bronchitis will generally be found to occupy at once the large bronchial 
tubes, some of the middle size, and more slightly the smaller ones. Its 
principal pathological characters are, the abundant secretion, the hy- 
pertrophy of the mucous crypts whose orifices are enlarged, hypertro- 
phy of the longitudinal fibrous tissue, and of the muscular fibres of the 
trachea and bronchi, and marked dilatation of the middle and terminal 
bronchial tubes. 

440. A word or two upon some of these details may not be amiss. 
The redness of the mucous membrane, which is very commonly seen, 

is not always present, even in very marked cases. It is generally dif- 
fused, and as visible where the membrane passes over the cartilaginous 
rings as in the interspaces. If it appear only in the latter, we may 
doubt whether it be not rather due to the subjacent tissues. 

There can be very little doubt that the mucous membrane is thick- 
ened, as the result of inflammation, although it is not very easy to 
demonstrate it ; nor can we attribute the obstruction of the smaller 
tubes entirely to this cause. 

MM. Billiet and Barthez occasionally met cases of bronchitis in 
which the mucous membrane was softened, thickened, and rough, but 
never any in which it was ulcerated. 

M. Barrier found it ulcerated only in cases in which tubercles also 
existed. M. Fauvel detected ulceration in one case of pseudo-mem- 
branous bronchitis. We must be careful not to mistake the enlarge- 
ment of the orifice of the mucous crypts for small ulcers. 

441. Bronchitis rarely continues for any length of time with infants, 
without causing dilatation of the bronchial tubes, as the direct conse- 
quence of inflammation. Sometimes it may be observed in the course 
of the tubes, in other cases at their extremities. In the latter case, if 
the lungs be incised, the surface presents a number of rounded areolae, 
and, if pneumonia co-exist, these are surrounded by denser tissue. Some 
care is necessary to demonstrate the dilatation of the branches of the 
bronchia), but it is not difficult to ascertain it. It is easy to understand 
how much this dilatation, if extensive, must increase the difficulty of 
breathing, by pressure upon other tubes ; and, if we remember that the 
quantity of secretion is excessive, Ave shall cease to be surprised at the 
amount of dyspnoea in capillary bronchitis. 

This secretion varies in character according to the extent and dura- 
tion of the inflammation. At the commencement there is little, if any, 
but in the course of a day or two we find a clear, viscid, frothy mucus 
expectorated, generally white, sometimes yellowish, if the attack be 
mild. But if it be severe, or of longer standing, the fluid is more puri- 
form, less aerated, and of a yellowish color. 

Rilliet and Barthez found occasionally shreds of false membrane 
mixed with the puriform matter, and in some cases false membrane 
alone. 

It is seldom that the large tubes are so far filled with it as to impede 
the entrance of air, but the smaller terminal ones are often completely 
choked up. 

M. Barrier has mentioned other accessory pathological phenomena, 



BRONCHITIS. 307 

discoverable upon dissection, as redness, swelling, softening, and some- 
times suppuration of the lymphatic glands, near the primary division of 
the bronchia ; an emphysematous condition of the lungs, depending upon 
a dilated condition of the vesicles. 1 

I may add, that the traces of lobular pneumonia are common, nor is 
it very rare to find tubercles, and some traces of pleuritis. 

Rilliet and Barthez have given the following numerical estimate of the 
occurrence of these morbid changes: In 174 autopsies of patients who 
died of bronchitis, redness of the mucous membrane existed in 143; and in 
thirty-four cases this was co-existent with softening and thickening. Out 
of the 174 cases, there was dilatation of the bronchial tubes in seventy- 
four ; in sixteen dilatation of the "vacuoles;" in seventeen there was 
vesicular bronchitis ; and in ten, false membranes were discovered in 
the bronchia. 2 

442. Modifications and Complications. — I have already alluded to 
secondary bronchitis, which is the most important modification of the 
disease. It is very common in many other diseases, especially the erup- 
tive fevers. We find it very troublesome in hooping-cough, measles, 
scarlatina, smallpox, infantile remittent, &c. &c. 

In many cases it proves a serious addition to the primary malady, 
requiring care, vigilance, and promptitude ; in other cases, the attack 
being slight, it is of no great consequence. Our judgment upon this 
point must be formed by a careful estimate of its intensity, the effects 
of the primary disease, and the state of the child's constitution. The 
symptoms and physical signs do not differ materially from those already 
described, but they may be masked, or our attention diverted from them 
by the importance of the original affection. 

443. The most frequent complication of bronchitis is lohular pneu- 
monia, and that kind of congestion which, if not checked, runs on into 
pneumonia. A careful examination in such cases may possibly detect 
dulness on percussing some portions of the chest, and there is a mixture 
of subcrepitus with the mucous and sibilant rales of bronchitis. I need 
not say that such a complication adds much to the danger; it renders 
the treatment somewhat more complicated and doubtful also. 

Again, the disease may give rise to emphysema, of the lungs, in con- 
sequence of the dilatation of the extreme ends of the bronchial tubes, or 
of the air-cells ; and we shall find the usual physical signs of the disease, 
enfeebled respiratory murmur, dry crepitus, and rather unusual reso- 
nance on percussion, if the tubes be not filled with muco-puriform secre- 
tion. Although it may add to the tediousness of the illness, I do not 
know that I could say that it adds to the danger. 

The disease may extend itself upward to the larynx and trachea, giv- 
ing rise not to croup, but to a modification of laryngitis, with hoarse 
cough and rough voice, but with no metallic sound. 

Lastly, it is a doubtful question how far bronchitis may be the fore- 
runner of tubercles. M. Fauvel says it is rare to find tubercles in these 
cases, and Rillet and Barthez confirm his statement, so far as the rapid, 
acute form is concerned, but they are not so clear that they may not 

1 Mai. de l'Enfance, vol. i. p. 344. 2 Mai. des Enfans, vol. i. p. 27. 



308 BRONCHITIS. 

complicate chronic bronchitis — whether as primary or secondary affec- 
tion may, of course, be doubted. Certain it is that in patients -who have 
died with bronchitis, tubercles, generally in a crude state, have been 
found. 

444. Causes. — Among the predisposing causes we must include other 
diseases, in the course of which bronchitis occurs as a secondary affec- 
tion. Thus, of 115 cases of simple bronchitis, Rilliet and Barthez 
found that but twenty-one were primary. It may also result from the 
suppression of an eruption to which the constitution is accustomed. 

Age appears to have an evident influence upon the production of 
bronchitis, whether primary or secondary. Rilliet and Barthez state 
that the majority of their cases were before the age of six years. Dr. 
Condie mentions that in Philadelphia, from 1835 to 1845, 1172 deaths 
occurred from bronchitis, of which 643 were children under one year ; 
276 were children from one to two years ; 201 from two to five years ; 
forty-seven from five to ten years; and five from ten to fifteen years of 
age.' Of twenty-three cases which occurred to Dr. Meigs, eight were 
under two years ; ten between two and four years ; three between four 
and six; and two between six and ten years of age. 2 

M. Barrier explains this by the greater demand for mucous secretion 
in infants, to protect the membrane from contact with the air ; and this 
normal activity, which is extreme, is on that account easily increased 
beyond the bounds of health. 3 

Primary bronchitis occurs most frequently in girls, and secondary in 
boys ; the latter owing, probably, to the greater frequency of the dis- 
eases in boys, in the course of which bronchitis occurs as a complica- 
tion. 

No doubt much depends upon peculiarity of constitution ; it is more 
common among weak and cachectic infants, or those with an hereditary 
disposition to catarrhal affections. It may be excited by cold, damp 
clothes, exposure to inclement weather, low, damp habitations, the 
prevalence of east or northeast winds, smoke or noxious gases, disordered 
liver, stomach, and bowels, or dentition. 

445. Lastly, either primary or secondary bronchitis may occur as an 
epidemic, and generally with considerable fever, dependent, probably, 
upon some peculiar atmospheric influence, constituting the formidable 
complaint which in France has received the name of " la grippe," and 
in these countries the influenza. Such was the epidemic of 1557, de- 
scribed by Valleriola; of 1580, by Sporisch ; of 1733, by Storch ; and 
of 1743, by Huxham, in which great numbers of infants perished. 

In a paper published by M. Petugain, on the epidemic of 1837 in 
France and Italy, he observes : " Infancy has escaped better than other 
ages in Paris, at Lyons, at Geneva, at Corbeil, at La Reole, at Milan, 
at Padua, and at Leipsic. At Lyons, out of three hundred intern stu- 
dents of the College, about two hundred were attacked, and of these 
eighty were under fifteen years of age. During the height of the epi- 

1 Diseases of Children, p. 88. 

* Diseases of Children, by Dr. Meigs, Jun., p. 106. 

3 Mai. de l'Enfance, vol.* i. p. 317. 



BEONCHITIS. 309 

demic, infants were most frequently attacked. Sick children as well as 
old people were seriously compromised by it. 

" The nasal mucous membrane was the seat of violent congestion, in 
consequence of which epistaxis was very common (one in ten, according 
to Brachet), which sometimes threatened danger by its abundance, in 
other cases afforded relief. Age exercised great influence upon the 
mortality. In London the disease made great ravages among old peo- 
ple, young children, and invalids. In Italy, as in France, it was old 
persons who chiefly suffered. At Geneva, more elderly people died 
than all other ages together. Very young infants, under two years, 
died in great numbers, according to M. Lombard." 

446. In the winter of 1846-7, the influenza prevailed very exten- 
sively in Dublin, though it did not prove very fatal. I shall give the 
following extract from a paper I published on the subject in the Dublin 
Journal, as the best description I can give of the epidemic : — 

" The number of cases that I have seen within the last two months, 
and from which my remarks are drawn, exceeds sixty ; and they em- 
brace children of all ages, from two months old to twelve or fourteen 
years. I may add that, in addition to the children, in many cases, the 
parents or servants were similarly affected. 

" I think that, without exception, the younger the child the more 
severe the attack. 

" The mode of invasion varied a good deal. In some instances the 
whole family seemed to submit to the epidemic influence at once, and 
all were laid up ; in others, one or two would present the epidemic 
character well marked, and the others complain merely of a slight 
cough, accompanied in a day or two by feverish symptoms ; whilst oc- 
casionally each child took sick successively, allowing the one first at- 
tacked to recover previously. 

" The characteristic features of the complaint, as in previous epidemics 
of influenza, have been affections of the chest, invariably accompanied 
by smart fever. Coughs and colds, without fever, are common enough, 
but I exclude them, as not true cases of influenza. 

" The fever sometimes precedes the cough, but more frequently comes 
on about the second, third or fourth day. The child is heavy, dull, 
cross, and cold, creeping to the fire, and unwilling to exert itself, or to 
share in its usual amusements. The skin becomes hot, florid, and the 
pulse very quick, ranging from 120 to 160. There is, perhaps, rather 
less thirst than one would expect from the degree of fever, and the 
secretion from the kidneys is scanty, and sometimes high-colored. The 
tongue is always foul, and loaded with white fur ; sometimes, though 
but rarely, dry ; the appetite is lost ; and occasionally I have seen 
vomiting or diarrhoea, but generally both stomach and bowels are steady. 
In almost all cases the child has been restless and uneasy at night, 
sleeping little, and in a few instances slightly delirious. 

" As regards the local affection, I have observed three varieties, 
often quite distinct, but occasionally two occurring in the same child. 

" I. In the milder form of the disease, the primary bronchial tubes 
were the portion of the respiratory system affected, and this was most 
common among the elder children. The attack began by a frequent 



310 BRONCHITIS. 

cough and a degree of hoarseness, indicating that the larynx and tra- 
chea were somewhat affected. The hoarseness often subsided, but the 
cough continued very troublesome, with free expectoration after the 
first day or two. In two case3 of young children (i. e. under four years 
of age), the larynx was more seriously affected, and the disease began 
by an attack of well-marked croup, which subsided in one case in ten 
or twelve hours, and in the other in two days, leaving behind it the form 
of influenza I am describing. 

" The cough gives a good deal of pain, and the elder children describe 
it as scraping the chest. After a day or two the fever is developed 
and the cough not less troublesome, and for some days the child suffers 
great distress ; until the fever subsides, the cough diminishes, and the 
expectoration becomes more abundant. 

" If the lungs be examined with a stethoscope, they will be found 
generally free from abnormal sounds, and the respiration vesicular and 
natural ; but the respiration through the large bronchial tubes gives a 
rough and slightly sonorous sound. Percussion yields a clear and per- 
fectly natural sound. 

" ii. The second form of the disease affected children of all ages, and 
consisted of more or less intense bronchitis of one or both lungs, with 
great congestion of those organ. In these cases respiration was much 
more rapid, and performed with some difficulty, a wheezing being au- 
dible at some distance. The imperfect aeration of the blood showed 
itself in the dusky red color of the cheeks, which, in some severe 
cases, were nearly livid. The cough was incessant, the mucus abun- 
dant ; but as little children do not expectorate, this rather added to 
the distress. The fever set in nearly as soon as the bronchitis, and in 
some cases ran very high. In some instances the attack was so severe 
that suffocation was imminent ; but these, with some difficulty and 
delay, recovered. 

" When the chest was examined, its movements indicated consider- 
able difficulty of respiration, and the respiratory murmur was lost in a 
variety of bronchitic rales, mucous, sibilous, and sonorous, varying ac- 
cording to the extent and intensity of the attack. Mixed with these is 
frequently heard a crepitus ; not the small, distinct crepitus of pneu- 
monia, but larger and more moist. Percussion yielded a pretty clear 
sound generally, with a diminution of tone occasionally in different 
parts ; mainly, I think, in those where the crepitus occurred. 

"In the progress towards convalescence the crepitus first disappeared; 
then the movements of the chest became less labored, and the respira- 
tions less frequent ; the distress diminished, and the fever subsided 
gradually. The bronchitic rales continued in a minor degree for a 
considerable time ; and, what was very remarkable, in a great number 
of cases, as the general bronchitis diminished, I found the primary 
tubes, and even the larynx became affected. 

" in. The third form which I observed the affection of the chest 
to assume was either simple pneumonia, or mixed with a moderate 
amount of bronchitis, and, I believe, this form occurred only in young 
children ; I do not remember any case of it in children above five 
years old. Its commencement in most cases was very obscure. The 



BRONCHITIS. 311 

child labored under high fever, with very rapid breathing, but very 
little cough. It looked very like a case of remittent fever, and in one 
or two cases I believed at the first moment it was so, and examined 
the chest as a matter of duty, to make sure, rather than with any ex- 
pectation of detecting serious disease. In these cases double pneumo- 
nia existed. The respiration in all was, as I have said, extremely 
rapid, with great action of the alae nasi, but without the labored move- 
ments of the chest, which occurred in the last variety ; the face was 
flushed, with the centre of the cheek of a florid red color ; the pulse 
very frequent ; the thirst considerable, with great restlessness. The 
usual crepitant rale of pneumonia, clear, small, and distinct, was pre- 
sent, mixed in a few cases with mucous or sibilant rales. The part of 
the chest affected was dull on percussion. Under the treatment adopted, 
the signs of pneumonia gradually disappeared, and, in proportion, the 
fever subsided, the cough generally increasing for a time, the chest be- 
came clear, and the little patient slowly recovered. 

" Of course this form of disease involved the greater danger ; and 
of some of the patients I had but slender hopes, as they were children 
of weak constitution. 

" As to the treatment, it has been simple and successful. On the 
accession of fever in all the varieties of local affection, I found it most 
advantageous to give an emetic of ipecacuanha in the two first, and of 
tartar emetic in the last, and to prolong the nausea for an hour or two. 
In the second and third varieties I found leeches necessary when the 
attack was severe, the respiration hurried and difficult, the pulse quick 
and strong, and the child able to bear them. 

" In most cases, after these preliminaries, I ordered a mixture of 
ipecacuanha wine, paregoric elixir, and almond milk, to be given at 
short intervals; but when pneumonia exists, the tartar emetic mixture 
is better, and if it should produce great depression, this may be cor- 
rected by ammonia. A small quantity of ammonia, in the former mix- 
ture, was advised by Dr. Stokes in some of the cases, and with imme- 
diate benefit ; it seems to relieve the congested state of the bronchial 
mucous membrane as much as anything I have tried ; or if it do not 
answer, from two to five drops of spirits of turpentine, in mucilage 
and water, every three or four hours, may be given ; in several cases 
it was very beneficial. If these mixtures disagree with the stomach, 
or after they have produced their effect, or at the same time that they 
are exhibited, small doses of calomel, ipecacuanha, and James's powder, 
may be given with advantage. 

"As to external applications, I found it necessary, in some cases, 
to have recourse to blisters, but not very frequently, partly on account 
of the annoyance they are to young children, but principally because 
I found a very good substitute in poultices, which I think worthy of 
a more extensive use than they obtain. They are best made of linseed- 
meal, and should be applied directly to the surface, warm, and very 
moist, changing them every two hours, or oftener. If irritation be de- 
sired, a dessertspoonful of the flour of mustard may be mixed with the 
meal. 

" Warm baths are exceedingly useful, and may be used every night, 



312 BRONCHITIS. 

provided the child do not cry much ; if it do, it will be better to bathe 
or foment the feet." 

447. Diagnosis. — There is seldom much difficulty in the diagnosis: the 
physical signs are generally sufficiently clear; the chest is sonorous on 
percussion, and there are abundant mucous and sibilant rales to be heard. 

I. The absence of crepitating rale and of dulness will ordinarily dis- 
tinguish the case from lobular pneumonia; but as the two diseases may 
be co-existent, of course we cannot come to so decided a conclusion in 
every case. 

II. The cough in capillary bronchitis occurs in paroxysms, like the 
kink in pertussis, and for some little time the absence of the hoop may 
not be conclusive ; but if this continue, and if the physical signs of 
suffocative catarrh predominate, we cannot have much doubt. 

in. It is more easy to mistake a case of chronic bronchitis for one of 
phthisis, inasmuch as we find cough, emaciation, evening exacerbations, 
and night-sweats, in both ; but a very careful examination of the chest 
will show that many of the physical signs of tubercles are absent, and 
that those of chronic bronchitis already noticed, which are present, 
differ considerably from those of phthisis. 

448. Prognosis. — The simple form of bronchitis is not in general 
very serious, unless it be secondary, and then its importance will rather 
be owing to the original disease. 

When the entire mucous membrane is affected, the case is, of course, 
very serious, and will often prove fatal. Suffocative catarrh is certainly 
the most fatal form of the disease in these countries. 

The increase of the dyspnoea, the severity of the cough, the feeble- 
ness and irregularity of the pulse, the oppression, anxiety, and rapid 
breathing, indicate a fatal termination to the attack ; while a gradual 
mitigation of the symptoms, diminished dyspnoea, a firmer, slower pulse, 
&c, are favorable. 

449. Treatment. — There is an important distinction between catarrh 
in the adult and in infants. When the first stage is passed with the 
former, and profuse secretion takes place, the disease is essentially over- 
come, and the patient rapidly becomes convalescent ; but in the infant, 
although a certain amelioration takes place when the second stage is 
established, we cannot always be sure of a favorable termination ; for 
if the bronchial secretion be prolonged, and if it occupy the smaller 
tubes, there is considerable danger of lobular pneumonia, unless the 
treatment be continued. 

The indications we should have in view are : 1. To diminish the in- 
flammation ; 2. To remove or lessen the secretion ; 3. To support the 
strength ; and 4. To relieve certain symptoms when it is impossible to 
do more. 

450. When the attack of simple bronchitis is slight, it will often be 
sufficient to exhibit demulcents and expectorants, with the use of a stim- 
ulating liniment to the chest. Almond milk, with ipecacuanha wine 
and syrup of squills, answers the purpose very well. 

Should the secretion be abundant, an emetic will be very useful ; and 
as the disease advances, the addition of a little paregoric will both re- 
lieve the cough, and, to a certain extent, control the secretion. 



BRONCHITIS. 313 

A poultice of bread and milk, or of linseed-meal, is very soothing, 
and if it be desirable to excite irritation, a little flour of mustard may 
be added ; or the compound camphor liniment used. 

451. But when the attack is more severe, it will be necessary to com- 
mence with more active measures. An emetic, followed by a warm bath, 
will generally afford some relief ; or it may be advisable to apply leeches 
to the chest, or to cup, regulating the amount of blood abstracted by 
the age and strength of the child. This will be particularly necessary 
when the breathing is much hurried, the pulse quick, and the skin hot, 
whether the affection be of the large tubes or the smaller. 

All authorities are agreed upon the propriety of bloodletting, and 
generally that it should be carried so far as to make an impression upon 
the disease, provided we see the child at the commencement of the at- 
tack. It is far less efficacious, and should be more cautiously used, at 
a later period. 

After the bleeding is stopped (which should be instantly, the leeches 
fall off), the child should be put into a warm bath, and then returned to 
a warm bed. A little calomel and James's powder may be given once 
or twice a day, with a purgative when necessary. The demulcent and 
expectorant mixture should be continued, but unless the secretion be 
very abundant, there is no object in repeating the vomiting. 

When the fever is lessened, and the pulse reduced in frequency, great 
benefit will be derived from counter-irritation, either by blisters or a 
strong liniment. Upon the whole, I think the blisters answer best ; 
but if we wish merely to irritate the skin, compound camphor liniment, 
or a linseed-meal and mustard poultice (one-third of the latter to two- 
thirds of the former), will be sufficient. This may be followed by an 
ordinary poultice, of the soothing, beneficial effects of which upon the 
lungs practitioners seem scarcely sufficiently aware. The best proof of 
this is, that the children like it, and ask for a second application. It 
should be applied to the surface with nothing intervening, and should be 
warm and moist. When it cools, it should be exchanged for a fresh one. 

452. In suffocative catarrh we must have recourse to similar reme- 
dies, but there are others which will be necessary. The decoction of 
senega root has been highly extolled, and I think with reason, espe- 
cially when combined with ammonia and ipecacuanha wine. The two 
remedies I have found most efficacious in relieving the smaller bronchial 
tubes, are ammonia, with ipecacuanha or tartar emetic, or spirits of tur- 
pentine. The formulae I generally employ are the following : — 

R. — Mist, amy gel al. §ij. 

Vini ipecacuan. gj vel antim. tart. gr. j. 
Carbon, ammonite gr. vj or gr. x. — M. 

A teaspoonful may be given to a child of a year old every three or 
four hours, and the quantity of ammonia may be increased or diminished 
according to the age. Or, 

Mucil. acacias, 
Syr. simpl, aa gij. 

Spts. tereb. rectif. gtt. xx to gtt. xxx. 
Aquae carui gij. — M. 
A teaspoonful to be given every two, three, or four hours. 



814 BRONCHITIS. 

From these medicines, I have found great benefit, after bleeding, 
warm baths, &c. In many cases, I have found the tartar emetic mix- 
ture act quite magically in relieving the chest ; but it is necessary to 
watch, lest it produce too much depression, in which case the ammonia 
may be increased or the tartar emetic omitted, or a little weak wine 
and water given. I quite agree with M. Barrier and others that active 
bloodletting is essential in severe cases of capillary bronchitis, and that 
it should be followed by other evacuants, as emetics, purgatives, &c; 
but in cases not so severe, and in weak delicate children, the tartar 
emetic supersedes the necessity for bleeding. 

Benefit will also be derived from small doses of Dover's powder, or 
the addition of a drop of laudanum to the expectorant mixture. 

Counter-irritation is of great value in capillary bronchitis, and cer- 
tainly blisters answer the purpose better than milder irritants. I have 
found more benefit with young children from a succession of small blis- 
ters than from a large one, with far less distress and exhaustion. A 
large poultice to the chest, without blistering, or over the dressing of 
the blister, has a most soothing effect. It should be changed every half 
hour, and continued for two or three hours. 

453. In that form of the disease described by Dr. Parrish, he ordered 
" a warm bath, sinapisms to the feet, a large blister over the breast, 
and laxative injections, containing assafoetida. But the remedy on 
which I chiefly relied was assafoetida, rubbed up with mint water, given 
frequently and in large doses." However, as other remedies were em- 
ployed, they may have had as much influence as the assafoetida. Dr. 
Parrish ordered a drachm of the gum to be rubbed up with an ounce of 
mint water, and a teaspoonful to be given every two hours. 

For the catarrhal fever described by Dr. Eberle, he first freely eva- 
cuated the bowels, and then, if the pulse were full and quick, leeches 
or the lancet were freely used; after which, antimonials, calomel, and 
ipecacuanha, with a mixture containing small doses of tartar emetic, 
were employed. When the febrile action had been moderated, small 
doses of Dover's powder were found beneficial. He found an occa- 
sional emetic very useful, and an expectorant mixture, composed of 
equal parts of paregoric, syrup of squills, and sweet spirits of nitre, 
with water. 

454. Chronic bronchitis will require a somewhat modified treatment. 
We cannot here use bloodletting very freely, nor in every case. I do 
not mean to say that there are no cases in which it may be necessary, 
but as a general rule it should be avoided. We must content ourselves 
with free evacuations from the bowels, an occasional emetic, repeated 
counter-irritation, diuretics, and expectorant mixtures, containing the 
stimulating balsams. 

Decoction of senega, with carbonate of ammonia, balsam of Tolu, 
Peruvian balsam, &c, will be found very useful. 

If, as is commonly the case, the disease be complicated, it will be of 
great importance to relieve the complication ; indeed, we shall scarcely 
overcome the chronic bronchitis without previously effecting this. 

In most cases, tonics will be necessary ; and of these, perhaps, some 
of the vegetable bitters, as quinine, infusion of cascarilla, gentian, &c, 



INFLAMMATION OF THE LUNGS. — PNEUMONIA. 315 

will be found the best. It may also be necessary to allow a better diet 
than in acute cases. 

455. In either form of the attack, but especially in the acute, it will 
be necessary that the air of the room the child inhabits should be fresh, 
and the temperature equable and warm. It is much better, even when 
the disease is slight, to confine the child to two rooms, and not to 
allow it to run about the house, as the frequent change of air irritates 
the delicate mucous membrane, and keeps up the cough. In capillar}' - 
bronchitis, it will be still more necessary to keep the infant in a warm 
temperature; and this course must be continued during convalescence. 
For some years past, I have been in the habit of recommending a very 
slight flannel waistcoat next the skin after these attacks, with the best 
effects. In fact, this climate is so variable that it is an excellent pre- 
caution to adopt at the beginning of winter, before the child takes cold; 
and children who can walk are so apt to stand still after heating them- 
selves that it is next to impossible to escape a chill without some such 
precaution. 

The diet of the child should at first be very moderate. In most 
cases, the appetite is lost, and no child will eat without one, so that 
there is no danger of overfeeding. As convalescence proceeds, we 
must gradually increase the quantity of the food, taking care to keep 
up the strength without overloading the stomach. 



CHAPTER VII. 

INFLAMMATION OF THE LUNGS. — PNEUMONIA. 

456. Inflammation of the substance of the lungs is a disease rarely 
or incompletely noticed by older writers, and often passed over very 
superficially by more modern authorities. We are more indebted to the 
researches of continental physicians than to those of our own countries 
for the information we at present possess. MM. Duges 1 and Guersent 2 
■were the first to investigate the subject, and they were followed by 
Leger, 3 Denis, 4 Brunet, 5 Gerhard, 6 Gumming, 7 Valleix, 8 Billard, 9 &c. ; 
but probably the most valuable contribution to the history of the disease 
is to be found in the works of Rilliet and Barthez, 10 Barrier, 11 and Dr. 
West, 12 of London. 

1 E,echerches sur les Mai. les plus import, et les moins connues des Enf. nouveaux-nes. 

2 Dictionnaire de Medecine. 3 Essai sur la Pneumonie des Enfans. 

4 Recherches Anat. et Phys. sur quelques Mai. des Enfans. 

5 Mem. sur la Pneumonie lobulaire. 

6 American Journal of Med. Sciences, vols. xiii. xiv. 

7 Trans, of Assoc, of College of Physicians in Ireland, vol. v. p. 28. 

8 Clinique des Mai. des Enfans nouveaux-nes. 

9 Traite de Mai des Enfans. 

10 Traite Clinique et Pratique des Mai. des Enfans, vol. i. p. 80. 

11 Traite pratique des Mai. de FEnfance, vol. i. p. 45. 

12 Lectures on the Diseases of Infancy and Childhood, p. 175. 



316 INFLAMMATION OF THE LUNGS. — PNEUMONIA. 

Notwithstanding that the disease has been so often slightly treated, 
it is sufficiently frequent in children of all ages and in different circum- 
stances. For example, the registered deaths in Great Britain for 1839 
show that 18,151 children — 10,000 males, and 8151 females died of 
pneumonia ; and in Philadelphia, during the ten years preceding 1845, 
of 26,510 deaths, there were 1592 cases of this disease. 

In the appendix to the Registrar-General's Report for 1841, we find 
that of 1,000,000 children living in the country, 905 died of pneumonia, 
and 2028 out of the same number of children living in towns. M. 
Guersent states that three-fifths of the children dying in Paris before 
the completion of dentition, die of this disease. 

This is sufficient to prove the frequency of the disease, and to show 
that it deserves our most careful and minute consideration. 

457. Recent researches since have established a distinction between 
pneumonia affecting an entire lobe of the lung, and pneumonia affecting 
the lobules. The former, lobar pneumonia, resembles the disease in the 
adult; the latter, lobular pneumonia, is peculiar to children, but some 
eminent authorities, Legendre, Fuchs, and I believe Dr. West, consider 
that the latter is not pneumonia, but atelectasis. According to Rilliet 
and Barthez, and Barrier, the latter is much more common than the 
former ; Rilliet and Barthez give the results of eighty-four cases of the 
former, and 203 autopsies of the latter. 

Of eighty-one cases of pneumonia, M. Barrier found twenty of lobar, 
and sixty-one of lobular pneumonia. We should bear in mind, however, 
that the proportion may differ, according as our observations include 
the children of the rich or those of the poor; those cases which we meet 
in private practice or in hospitals. 

Mr. Friedleben conceives that true lobar pneumonia is very frequent 
in early life, and that lobular pneumonia is for the most part confined 
to the first year. 

But, what is of more practical importance, either form may be pri- 
mary or secondary, although, as Barrier observes, lobular pneumonia 
more frequently constitutes the secondary attack. 

I shall endeavor to lay before the reader a short sketch of the cha- 
racteristic symptoms of each variety, and then notice the difference to 
be observed according as the disease is primary or secondary. 

458. Symptoms. — I. Lobar Pneumonia. — This form of the disease, 
at least when primary, is rarely preceded by catarrh ; the child exhibits 
a degree of fever, with a hot skin, quick pulse, thirst, &c, for a few 
days, during which time a short cough may be observed, less strong and 
frequent than in adults, dry at first, and with little or no effort at expec- 
toration. This cough continues, and increases in frequency in most cases, 
but we have not the advantage of the peculiar expectoration of adults, 
for very young infants swallow the expectoration, if there be any, and 
in general up to five years of age it is not peculiar ; from five to fifteen, 
although the pneumonic sputa may frequently be observed, they are 
absent in many cases. 

Very often the cough is not accompanied with pain in the chest, but 
in some cases, when the child is old enough to complain, we find pain 
circumscribed to the seat of the disease ; in others, it is diffused and ob- 



INFLAMMATION OF THE LUNGS.— PNEUMONIA. 317 

scure, sometimes at the epigastrium and radiating to the abdomen ; 
sometimes near the base of the lung. Dr. Gerhard observed it most 
frequently at the anterior edge of the axilla. 

The dyspnoea, Barrier remarks, is greater than in adults; " thus it is 
not rare to find a pneumonia occupying the lower half of one lung cause 
from forty to sixty respirations per minute, -whilst in the adult it would 
require very extensive disease to produce the same effects." 1 And 
from a careful register of nine patients, he finds that the frequency of 
the movements of the thorax, compared to those of the heart, were as 1 
to 2.69. 

459. The respiration, then, is short and rapid ; from 40 to 60 or 
80 per minute. Nay, Dr. Cumming 2 mentions a case in which it 
amounted to 118 ; but although the frequency may in part be owing to 
the amount of disease, it appears to be partly an involuntary precaution 
to avoid the irritation and cough consequent on a full inspiration. Some- 
times this hurried respiration intermits, and for a short time the respi- 
ration seems natural ; but very speedily the rapid movement is resumed. 
This acceleration of the respiration and pulse is said to be at its height 
on the fourth or fifth day ; and by the seventh or ninth, if the case pro- 
gress favorably, the pulse diminishes in frequency, and the respiration 
becomes more calm and deliberate. 

If the disease increase, the respiration becomes more labored, not 
less rapid, but with greater muscular effort ; the chest heaves, the alse 
nasi dilate, and even the momentary interruption caused by speaking 
seems to add to the distress of the lungs. There is an effort now and 
then to fill the lungs by gaping, sighing, &c, but it appears to be in- 
effectual ; the congestion is so great that it impedes both the circulation 
in the lungs and the respiration. 

Rilliet and Barthez have remarked that the irregular, abrupt respi- 
ration occurred almost exclusively when the summit of the lung was 
principally affected. When the disease proves rapidly fatal, the fre- 
quency of respiration goes on increasing until death ; but when the dis- 
ease is prolonged, we may observe a diminution during the last few days, 
not from any amelioration, but probably from a degree of organic in- 
sensibility. 

The pulse is very quick from the beginning, seldom under 120, even 
in cases where the distress does not appear very great ; but it often 
exceeds this, and may reach 140, 160, or even 180, especially with 
young children. At the commencement it is generally full, strong, and 
regular, and in favorable cases it gradually becomes softer and slower; 
but in unfavorable, whilst it preserves its frequency, it becomes ex- 
tremely small, irregular, and ' at length insensible. The heat of skin 
bears a relation to the rapidity of the circulation ; during the first part 
of the attack, the skin is dry and very hot ; towards the end, in unfa- 
vorable cases, although the pulse is equally, or even more rapid, the skin 
becomes cooler, and moistened with clammy perspiration. 

The decubitus is sometimes dorsal, sometimes on one side or the 
other, apparently owing to the effect upon the thoracic pain or uneasi- 
ness. 

1 Mai. del'Enfance, vol. i. p. 193. 2 Trans, of Association, vol. v. 



318 INFLAMMATION OF THE LUNGS. — PNEUMONIA. 

The expression of the face is that of great distress, sometimes flushed, 
sometimes pale, or more frequently with a patch of vivid red on one or 
both cheeks. The alae nasi are in active operation, dilating just before 
or with each inspiration, and the nares are dry, for young infants rarely 
breathe through the mouth. Billiet and Barthez have noticed the blue 
circle which appears beneath the eyes, and which increases with the 
progress of the disease, especially when there is much emaciation. 

460. The physical signs of lobar pneumonia are of great impor- 
tance, from the frequent absence of the characteristic sputa of pneu- 
monia. They, however, do not differ much from those observed in the 
adult, and therefore I need not dwell at length upon them. Percussion 
yields a distinct dulness of sound in the affected part, compared with 
those portions of the lungs which are free ; but we must be on our guard 
against making the opposite side a standard of comparison, as both 
lungs are frequently involved ; different portions of the lungs, as well 
as both sides, must be carefully percussed, and it will rarely be difficult 
to satisfy ourselves. 

The crepitant or sub-crepitant rale will be heard in those parts of the 
lungs still in the first stage of inflammation ; but when the respiration 
is very quick and short, it is less characteristic, and will require that 
we make the child cough, or take a deep inspiration. With infants who 
cannot comprehend our directions, the best way is to stop the breath 
for a moment ; the effort to resume it will insure a deep inspiration. 
The rale may occupy a small portion, or nearly the whole of the lung ; 
it may be heard at the superior, middle, or inferior portions. Not un- 
frequently, when one lung only is affected, we shall find puerile respira- 
tion in the other. 

When extensive hepatization has taken place, little or no crepitus 
will be audible, except around the diseased portion, but instead we may 
find bronchial respiration, and something resembling bronchophony, 
with extreme dulness. 

In the third stage, the stethoscopic signs are pretty nearly the same 
as in the second, except that the bronchial respiration is more distinct 
and also more extensive, occupying situations where crepitation had not 
previously been heard. It becomes audible in front as well as posteri- 
orly, and is perceived, along with dulness on percussion, in the infra- 
mammary, as well as in the infra-scapular region. It is generally more 
extensive on one side than the other, and occasionally it is audible 
throughout the entire back part of one side of the chest. It is never 
confined to the upper part of the lung, unless there have existed pre- 
viously tubercular disease. 

Dr. West observes that bronchial respiration must always be con- 
sidered of serious import ; in eleven out of twenty cases of pneumonia, 
where it existed, the disease terminated fatally. 

461. The appetite is lost from the beginning in severe cases ; the 
tongue is white and loaded, sometimes moist, but generally dry, probably 
from the endeavor to breathe through the mouth ; and the thirst is con- 
siderable. In very young children Dr. West has noticed a peculiarity 
of sucking. 

Vomiting occurs occasionally at the commencement of the disease, 



INFLAMMATION OF THE LUNGS. — PNEUMONIA. 319 

and more frequently than with adults ; subsequently it is generally the 
consequence of medicine. Diarrhoea, on the other hand, is rare, except 
towards the termination, or when caused by the remedies. 

The secretions are irregularly and variously affected ; the urine is 
high-colored at the beginning, and occasionally scanty, but in many 
cases but little altered. The liver is less affected than in adults ; never- 
theless, jaundice does sometimes, though rarely, occur, and in such 
cases, MM. Chomel and Eouillaud 1 conceive the base of the right lung 
to be the seat of the disease, and the jaundice to be the result of its 
proximity to the liver; but M. Grisolle has adduced evidence to show 
that this can scarcely be the reason. 2 Others have asserted that the 
jaundice is not the result of the peculiar condition of the liver, but of 
the incomplete hrematosis caused by the pneumonia, and that it is analo- 
gous to the jaundice determined by purulent infection. 

It is unnecessary to state that the strength of the patient is greatly 
depressed, and that in a very few days it is in every way alarmingly 
reduced. 

The nervous system does not escape ; there is generally a good deal 
of anxiety and agitation, especially at night. In other cases there is 
headache, and a degree of stupor ; in a few cases delirium or convul- 
sions.. 

In some cases, as M. Tonnelier has remarked, these nervous symp- 
toms may be the result of sympathetic irritation, but in others they 
appear to depend upon coincident meningitis. 

462. Duration and Termination. — Lobar pneumonia in children, 
like the same disease in adults, commences, as we have seen, by rigors, 
heat, cough, pain in the chest, hurried respiration, dyspnoea, and quick 
pulse ; these symptoms continue, and perhaps increase for a time, but 
when the treatment is successful they gradually diminish. The pulse 
becomes slower, the respiration calmer and less labored, the pain dis- 
appears, and the cough is softer ; then the appetite returns, the tongue 
becomes clean, and the strength is gradually regained. 

Unfavorable cases, on the other hand, are marked by an increase of 
the symptoms, the respiration becomes more hurried and labored, the 
aloe nasi moving incessantly ; the cough short, frequent, and distressing ; 
the pulse small, weak, quick, and at length irregular or intermitting ; 
the face livid ; the eyes sunken ; the lips purple, and the surface cold 
and clammy. 

Upon the whole, in primary lobar pneumonia the result is favorable ; 
only one in twenty of M. Barrier's patients died. 

The duration of the disease varies somewhat : it is seldom less than 
from six to twelve days, generally from twelve to eighteen, and fre- 
quently longer. Dr. Gerhard states the mean duration to be fifteen days. 

Of fifteen uncomplicated cases M. Barrier mentions that the disease 
lasted ten days in four cases ; eleven in two ; twelve in one; thirteen in 
one ; fourteen in three ; and sixteen, eighteen, twenty, and twenty-five 
in one case each. 

463. Lobular Pneumonia. — We will now enumerate the symptoms 

1 Clinique, vol. ii. p. 138. 2 Traitg de la Pneumonie, p. 384. 



320 INFLAMMATION OF THE LUNGS. — PNEUMONIA. 

of lobular pneumonia, which differ in some particulars from those just 
described, and which, in many cases at least, may be chiefly owing to 
the disease being secondary, or occurring in the course of some other 
malady. 

In almost all cases it is preceded by pulmonary catarrh ; either the 
latter is the primary disease, upon which pneumonia supervenes, or, 
being secondary to some other primary disease (as measles, for instance), 
it runs on into pneumonia. 

It occurs also more generally in infants and young children, than 
lobar pneumonia. Of sixty-one cases related by M. Barrier, twenty 
occurred from two to three years, and twenty more under five years of 
age, which will account also for some obscurity in those symptoms which 
depend upon the patient's description. For example, we have reason 
to believe that there is pain or uneasiness in the chest, but with young 
infants this can only be suspected from their crying when the cough 
comes on. In older children it does not appear to be acute and circum- 
scribed, but diffused, and principally in the region of the diaphragm, 
not troublesome ordinarily, but excited by coughing. 

The cough is an important symptom ; no doubt it exists before the 
pneumonia sets in in secondary attacks, but even then its increase will 
mark the accession of the more serious disease. It continues short and 
troublesome, dry or moist, until the decline of the disease ; but in fatal 
cases it often disappears for two or three days before death. 

In some rare cases of latent pneumonia, the cough is nearly absent, 
and these occur generally in weak, cachectic children. 

The cough does not occur in kinks, neither is it hoarse, unless the 
disease be complicated. We can derive but little assistance from the 
expectoration, for in many cases there is but little secreted, and by in- 
fants and young children it is always swallowed ; but, from some obser- 
vations he made, M. Barrier is of opinion that, if it occurred, the sputa, 
in many cases, would exhibit the pneumonic character. 

The dyspnoea and hurry of respiration are in proportion to the extent 
of the bronchitis and pneumonia, and fully as much owing to the former, 
when severe, as to the latter. Thus, with intense catarrh and a pneu- 
monia of moderate extent, the respirations will occasionally amount to 
fifty or sixty per minute. 

On the other hand, when the pneumonia is extensive, and the bron- 
chitis slight, the respiration will be found very rapid and short, with 
free motion of the alse nasi, and ultimately of the chest and abdomen. 

"Moreover," M. Barrier observes, "it is not merely by the number 
of respirations per minute that we must judge of the extent and gravity 
of the lesions of the lungs. We must also observe whether the respira- 
tion be superficial or profound, if it be easy or painful and anxious, 
costal or abdominal, regular or irregular. In general, the more fre- 
quent, deep, and anxious it is, the more serious is the attack. But we 
must not forget that occasionally we find the respiration increased in 
infants for a few minutes, without apparent cause, and that it soon sub- 
sides again." 

464. The physical signs are of great importance, even though they 
may not be quite so definite and certain as in adults. Dr. Gerhard 



INFLAMMATION OF THE LUNGS. — PNEUMONIA. 321 

lays great stress upon the dulness on percussion ; he conceives it in 
many cases of more use than auscultation. M. Vernois found the dul- 
ness very marked in twenty out of twenty-two cases, and slight in 
the remaining two. M. Valleix found dulness in twelve out of sixteen 
cases, seven times on the right side, and five times on both sides. Ril- 
liet and Barthez found but little deviation from the normal sound in 
partial or mammelonated pneumonia, but decided dulness in the gene- 
ralized form. 

M. Barrier states, that in " disseminated lobular pneumonia" the 
results of percussion are completely negative, and that there is no dulness 
unless from some complication ; but that, when the disease has gradually 
spread and coalesced in " generalized lobular pneumonia, the sound is 
dull on percussion." 1 

My own experience coincides with Dr. West's, who remarks : " Per- 
cussion sometimes yields a very manifest dulness on the affected side ; 
and this dulness is usually most evident in the infra-scapular region. 
At other times, however, no such marked results are afforded, but the 
lower parts of the chest yield a somewhat duller sound than the upper, 
and the impression communicated to the finger is that of greater solidity 
below than above the scapulae. This last sign is very valuable, since it 
may be perceived at a time when the ear cannot clearly detect any 
actual dulness on percussion." 

In the disseminated or partial form of the disease we find the sub- 
crepitating and mucous rales, with an occasional mixture of the sibi- 
lant. Rilliet and Barthez lay great stress upon the subcrepitant rale, 
as being often the only sound to be heard throughout the course of the 
disease. It is generally audible at the back of the chest, sometimes in 
front, and at different points, according as the lobules affected may be 
distant or near. 

The true crepitant rale is much rarer in infants than in adults, al- 
though it is occasionally audible for a few moments. 2 If one lung only 
be affected, we shall find the subcrepitant rale on one side and puerile 
respiration on the other ; but if both be affected, as Dr. West remarks, 
we may overlook the disease, owing to the absence of contrast, unless 
the disease of one lung be so far advanced as to give rise to bronchial 
breathing, whilst in others nothing but the subcrepitus can be de- 
tected. 

At a more advanced period, or, what is much the same thing, in the 
" generalized lobular pneumonia," we have present more or less of the 
preceding phenomena, but with certain modifications. The diseased 
portions having coalesced, and the lung having become more generally 
solid, we find bronchial breathing, both in expiration and inspiration in 
one or both lungs posteriorly, and even bronchial rales and broncho- 
phony. The subcrepitant rale has changed a good deal, the bubbles 
are smaller, and the crackling much finer; in fact in many cases we 
find the pure crepitating rale of lobular pneumonia, as in the adult, 
especially when the disease is superficial. 

1 Mai. del'Enfance, vol. i. p. 105-7. 

2 Trousseau and Lasegue, Arch GCn. de Me"d., vol. xxvi. p. 130. 

21 



322 INFLAMMATION OF THE LUNGS. — PNEUMONIA. 

Occasionally these more defined phenomena of pneumonia are masked 
by the great amount of moist rales, but even these have a sort of me- 
tallic sound in this disease, which, taken along with the vocal reso- 
nance and the dulness on percussion, may prevent an error in our 
diagnosis. 

With regard to the vocal sounds, Dr. West observes : " In the child 
we lose all the evidence which in the adult is afforded by the different 
modifications of the voice sound ; for the shrill or querulous tone of a 
suffering child, and the words, often uttered in very different keys, 
yield, even when the child is old enough to talk well, results far too 
uncertain to be trustworthy." 1 

465. The external appearance of the infant is not characteristic ; it 
will show that the chest is affected, but not the peculiar form of dis- 
ease. Thus, the face may be pale or colored, swollen and puffy, or 
red ; very often, while the rest of the face is pale, there is a bright 
spot of red on one or both cheeks. The alee nasi will be found in ac- 
tion in proportion to the hurry and difficulty of respiration, and the eyes 
appear sunken. 

The patient lies generally on his back, but is not more distressed by 
lying on one side than the other, which may be because the pneumonia 
is frequently double. 

The pulse varies very much, of course, but it is generally in propor- 
tion to the extent of the inflammation; it may range from 100 to 110, 
with but little heat of skin, in weak, delicate children ; to 140, 160, 
or 180, with high fever, in others. Towards the termination, it either 
gradually becomes slower and more natural ; or quicker, weaker, and 
irregular, according as the result is favorable or unfavorable. The 
usual relation between the respiration and circulation is destroyed ; in 
the adult suffering from pneumonia, it is as 1 to 4 ; in infants, it is as 
1 to 2 or 3. 

The digestive system is more or less deranged ; vomiting is frequent 
at the commencement of the disease, but rare subsequently. Intestinal 
catarrh, according to M. Barrier's experience, precedes the attack of 
pneumonia in many cases, and in others we often have diarrhoea in the 
course of the disease, especially when it is secondary to measles ; and 
in these cases, if the pneumonia be extensive and advanced, it will be 
a very unfavorable addition ; but if the result of calomel or tartar 
emetic, it is not of so much consequence. Besides this diarrhoea, how- 
ever, we have no symptoms of intestinal inflammation ; there is neither 
pain, tenderness, nor tympanitis. 

As in lobar pneumonia, we may have a certain degree of sleepiness, 
indifference or cloudiness of intellect ; nay, even some more marked 
nervous affections, as anxiety, agitation, contractions or convulsions, 
and delirium. 

466. I. Termination and Duration. — As I have described it, lobular 
pneumonia may continue steadily advancing, the symptoms increasing 
in gravity, and the constitution suffering more severely, until death. 
Or, the disease having arrived at its maximum of intensity, the symp- 

1 Lectures on Diseases of Infancy and Childhood, p. 195. 



INFLAMMATION OF THE LUNGS. — PNEUMONIA. 323 

toras may gradually diminish ; and, if the termination is to be favor- 
able, this amelioration will affect both the general and local symptoms. 
In some cases, we have an improvement in some one or two symptoms 
for a time, and then a return. Such cases generally terminate fatally. 

It is more difficult to fix the duration of lobular than lobar pneumo- 
nia, because the former being most frequently secondary, and stealing 
on more or less insidiously, we cannot ascertain the exact period of 
invasion. Rilliet and Barthez give the following duration in eighty- 
three cases : in twenty, it lasted from one to five days ; in nineteen, 
from six to ten days; in sixteen, from eleven to fifteen days ; in twenty, 
from sixteen to twenty-five days ; and in eight, from twenty-six days 
upwards. 

M. Barrier remarks that those cases which are cured are of the long- 
est duration ; the fatal cases he has never known to last longer than 
from twenty-five to thirty days. The others may run on for a month 
or two. 

M. Friedleben states that in the great majority of children, the first 
stage lasted for twelve hours, the second for three days, the third from 
five to seven days, after which convalescence commenced, but that it 
sometimes proves fatal in from twelve to twenty hours. 

467. II. Lobular pneumonia may result in abscess of the lung, as a 
termination ; but probably in most cases it will escape detection unless 
purulent matter be expectorated. This, and a large mucous rale, ap- 
proaching to a gurgle, may enable us to suspect the existence of an 
abscess when the bronchial tubes communicate with it. In other cases, 
it may be impossible to decide. Moreover, as these abscesses tend to 
the surface, and occasionally open into the pleura, the very sudden 
occurrence of pleurisy may lead us to suspect a perforation. 

468. hi. In some rare cases, pneumonia terminates in gangrene; the 
symptoms are those of pneumonia, with extreme depression of strength, 
profound constitutional suffering, and a rapid course. It seems more 
apt to attack children, during exanthematous fevers, whose constitution 
has been much deteriorated ; and it is not uncommon to find, at the 
same time, gangrene of some other parts. Of eighteen cases of gan- 
grene mentioned by Rilliet and Barthez, three had gangrene of the 
mouth, one of the pharynx, two of the oesophagus, one of the larynx 
and pharynx, one of the bronchial glands and spleen, one of the glands, 
pleura, and oesophagus, and one of the pleura alone. In Dr. West's 
case, there was gangrene of the mouth. From all the circumstances, 
Dr. West infers, and, I think, with great probability, that the gangrene 
is due rather to some peculiar morbid alteration of the circulating fluid 
than to the violence of the inflammatory action. 

469. Such are the characteristics of lobar and lobular pneumonia. 
Either may be primary or secondary; but the lobar is more frequently 
primary, the lobular secondary. 

The principal differences are in the mode in which each commences, 
in the greater amount of fever, the dulness on percussion, the crepitating 
rale, and the quicker termination of the former; the insidious approach, 
the greater obscurity of the physical signs, the slight dulness on per- 
cussion in the first stage, the diffused subcrepitant rale, the different 



321 INFLAMMATION OF THE LUNGS. — PNEUMONIA. 

points at which it is heard, and the changes which it undergoes subse- 
quently, the greater duration and greater fatality, of the latter. 

470. Now let us examine the different characters of primary and 
secondary pneumonia, whether lobar or lobular. 

Primary pneumonia commences by intense fever, with occasionally a 
slight bronchitis preceding, in very young children. The respiration is 
always rapid, with thoracic pain occasionally, and a short, dry cough. 
Auscultation reveals the existence of crepitant or subcrepitant rales on 
one side of the chest, and especially towards the base of the lung. 

Vomiting occurs at the beginning, and occasionally diarrhoea. There 
is anxiety, agitation, and sighing. As the disease advances, some of 
these symptoms disappear, and new ones appear. The fever rather 
increases, as does the dyspnoea and hurry of respiration ; the alse nasi 
are observed to move extensively, and more effort is required to breathe; 
the cough is very troublesome, short, and painful; expectoration makes 
its appearance, except in young subjects ; the pulse is very quick; the 
crepitating or subcrepitating rale gives place in some portions to bron- 
chial respiration and bronchophony, and the chest yields a dull sound 
on percussion. 

These symptoms attain their height about the fifth or sixth day; but, 
after the eighth or ninth day, in favorable cases, they begin to subside, 
the fever diminishes, the pulse and respiration become slower, the alee 
nasi are quiescent, the heat of the skin subsides, the large subcrepitant 
rale is freely heard, with bronchial breathing more rarely, and chiefly 
in expiration. The sound of the voice is diffused, and the dulness less 
marked. By degrees, the appetite returns, the spirits and strength of 
the child are recovered, the cough diminishes, the fever altogether dis- 
appears, and the patient becomes convalescent. 

471. When pneumonia supervenes upon another disease, or is second- 
ary, it presents very different characters, and the difference is greater, 
according to Rilliet and Barthez, the earlier the secondary affection 
supervenes upon the primary disease. 

Secondary pneumonia (most frequently lobular) is apt to steal upon 
us very insidiously, the pulse, respiration, and countenance, affected by 
the primary disease, undergoing but little change. The cough may be 
troublesome, but there is little thoracic pain, and no expectoration. If 
no cough existed previously, we shall be induced, probably, to examine 
the lungs, and thus the complication will be detected. The subcrepitant 
rale will be heard on one or both sides posteriorly. As the disease 
advances, the fever will increase, the pulse become quicker, the respira- 
tion more hurried, the cough more constant; the strength diminishes, 
and the face will have a worn, anxious, and distressed expression. The 
chest will gradually become dull on percussion ; and, with the subcrepi- 
tant rales, we may also hear bronchial respiration and bronchophony, 
increasing in intensity and extent. The primary disease will generally 
be found to have undergone an unfavorable change, and with these 
unfavorable symptoms will at length be found others, such as feeble and 
irregular pulse, violet color of the face, great dyspnoea, coldness of 
extremities, &c, which denote the approach of death. 

We can readily understand that the secondary must be more fatal 



INFLAMMATION OF THE LUNQS. — PNEUMONIA. o^O 

than the primary, because the child has to combat a second most for- 
midable disease, at a time when his strength is reduced, and his con- 
stitution shaken, by a previous one. 

Of sixty-one cases noted by M. Barrier, forty-one died. 

472. Complications. — When we recollect the anatomy of the lungs, 
and consider their contiguity with the tissues which line or surround 
them, we cannot be surprised at other affections supervening in the 
course of pneumonia. 

I. Bronchitis. — In a great majority of fatal cases, evidences of in- 
flammation of the bronchial mucous membrane are found after death, and 
in a very large number we can ascertain its existence during life, either 
as a primary or secondary affection. Barrier has proved that lobular 
pneumonia is preceded, in a very large proportion of instances, by pul- 
monary catarrh, and that it is, probably, an extension of this latter affec- 
tion. Rilliet and Barthez have drawn the following conclusions from 
their experience : — 

" 1. That the bronchitis which coincides with pneumonia is almost 
always an affection of the small tubes. 2. That in a great majority of 
cases it co-exists with lobular, mammelonated, partial, and generalized 
pneumonia ; more rarely with lobar pneumonia. 3. That bronchitis, 
with dilatation, is found almost exclusively in infants who have died of 
partial or generalized (lobular) pneumonia ; almost none in those who 
have suffered from lobar pneumonia. 4. That bronchitis exists almost 
always either in the centre of the part hepatized, or in the portions sur- 
rounding it, but that it may occur elsewhere. 5. That dilatation of the 
bronchi is frequent in the carnified tissue." 1 

473. II. Pleuritis is a frequent complication of pneumonia, and so 
intense is it occasionally that the disease may well be called, as it is by 
some, pleuro-pneumonia. About one-fourth of Rilliet and Barthez's 
patients, attacked with lobular pneumonia, exhibited traces of recent 
pleurisy. The proportion of those suffering from lobar pneumonia, who 
had secondary pleurisy, was even higher ; it amounted to one-half. I 
do not think that the complication is so frequent in this country, or in 
private practice; but still it does occur, and adds much to the danger. 
In most cases it is extremely difficult to detect the presence of pleurisy, 
the symptoms, and even the physical signs, being masked by those of 
the existing pneumonia; but now and then we may arrive at a just con- 
clusion. 

474. in. When we consider the extreme difficulty of the respiration 
in some cases, and the violent efforts made by the child, we shall not be 
surprised that the disease is occasionally complicated by emphysema, 
which is in general in proportion to the extent of the pneumonia and 
bronchitis, to the acuteness of the disease, and to the amount of dys- 
pnoea which is present. 

475. IV. I have already mentioned that lobular pneumonia is occa- 
sionally complicated with convulsions and other cerebral affections of 
minor degree. Six of M. Barrier's cases were thus attacked and died. 
In three there were proofs of meningitis. 

1 Mai. des Enfans, vol. i. p. 75. 



326 INFLAMMATION OF THE LUNGS. — PNEUMONIA. 

476. But in many cases the pneumonia, whether lobar or lobular, but 
far more frequently the latter, is secondary, and occurs as a complica- 
tion in the course of other diseases. 

It occurs most frequently in the course of measles, but we find it com- 
plicating scarlatina and other febrile eruptions, hooping-cough, croup, 
pleurisy, bronchitis, cancrum oris, intestinal catarrh, typhoid fever, &c. 

477. Morbid Anatomy. I. Lobar Pneumonia. — I need not enter at 
length upon the post-mortem appearances found in lobar pneumonia, as 
they are identical with those in the adult, and will be found laid down 
in all the modern books on the subject. We find in infants evidences 
of congestion, red and gray hepatization, extending from the base of 
the lung towards the summit, but very rarely terminating in abscess. 
Dr. West has stated the result of forty-seven cases carefully noted : in 
five, the first and second stages of pneumonia co-existed, and in four, 
the first and third ; in thirteen, the second and third ; in eleven, all 
three stages ; in three, the first stage only ; in six, the second stage ; 
and in five, the first stage only ;* and this, as he observes, agrees very 
closely with the results obtained by M. Grisolle in the adult. In forty 
cases, he found that the first and second stage co-existed in four ; the 
first and third in three ; the second and third in sixteen ; all these stages 
in two cases ; the second stage only in seven ; and the third stage only 
in eight. 2 

It resembles the pneumonia of adults, also, in being more frequently 
single than double, and more common in the right lung than the left. 
Of 1430 cases in the adult, M. Grisolle states that 742 were on the 
right side, 426 on the left, and 262 double. Of eighty-four cases in 
children, given by Rilliet and Barthez, forty-eight were of the right 
lung, twenty-seven of the left, and nine double. Of M. Barrier's 
twenty cases, ten were of the right lung ; six of the left ; and four were 
double. In cases of double pneumonia, both lungs are pretty equally 
affected. 

Of seventy-five cases in which a single lung was affected, Rilliet and 
Barthez found forty-eight in which the base, and twenty-seven in which 
the summit of the lung was diseased ; and of the latter, twenty-three 
were of the right, and four of the left lung. 

M. Barrier, in twenty cases, found the entire lung affected in three 
cases ; the inferior lobe in twelve ; the superior in four; and the supe- 
rior lobe with the upper part of the inferior in one case. 

Observation has also proved that the posterior portion of the lung is 
more frequently affected than the anterior ; and even when the post- 
mortem examination shows both to be involved, the history of the case 
would lead us to the conclusion that the disease commenced posteriorly. 

478. II. Lobular Pneumonia. — Considerable difference of opinion 
exists as to the true nature of lobular pneumonia, and the exact cha- 
racter of its pathology. It appears to me that its existence as an in- 
flammatory disease is fairly established, and without pronouncing upon 
the opposite views of Legendre and Bailly, Fuchs, &c, I shall first lay 

1 Lectures on Diseases of Infancy and Childhood, p. 176. 

2 Traite" de la Pneumonie, p. 18. 



INFLAMMATION OP THE LUNGS. — PNEUMONIA. 327 

before the reader the ordinary appearances, and by and by refer to 
the different pathological views held by these ingenious observers. 
Anatomically speaking, lobular pneumonia is so called from its occupy- 
ing one or more lobules ; and it has been divided into several varieties, 
mammelonated, disseminated, partial, generalized, with an additional 
species, by M. Barrier, which he calls pseudo-lobar. 

"When we examine," observe Rilliet and Barthez, "the lungs of 
subjects who have died from this disease, we find them extremely soft 
and flaccid, of a grayish rose color, with patches of violet red here and 
there, generally circumscribed, prominent, solid under the finger, and 
not collapsing when the chest is opened, as the surrounding pulmonary 
tissue does. These patches, ordinarily circular, but sometimes elongated 
from above downwards, are most frequent at the posterior edge of the 
lung, but are to be found on other portions. Occasionally they are not 
visible ; but nodosities, more or less deep, can be felt in the substance 
of the organ." 

When cut, the lung presents a marbled appearance, of a grayish red 
color, mixed with violet red, the latter corresponding to the external 
red patches; and we see that these patches and the deeper nodosities 
are centres of congestion and hepatization, whose characters resemble 
those of pneumonia generally ; i. e., the surface cuts smoothly, is granu- 
lar when torn, easily penetrated by the finger, and sinks when placed in 
water. On pressure, these portions of the lung crepitate very little, or 
not at all, but a sanious frothy fluid escapes : from the central portion, 
if pressed, we obtain a red serous fluid, without air, as in lobar pneu- 
monia. 

The three degrees of pneumonia may be observed : the first with the 
tissue marbled, of a rose and gray color; the red portions, irregularly 
limited, somewhat less resisting than the neighboring parts, floating in 
water ; when pressed giving forth a frothy fluid, and crepitating under 
the finger. This is the first degree ; the second has just been de- 
scribed. 

The third degree is characterized by a gray, yellow, or yellowish gray 
color, owing to the infiltration of pus in the pulmonary parenchyma. 
The tissue is very friable, and pressure expresses a purulent fluid. 
When the tissue is chiefly gray, it is possible to mistake the disease, 
unless care be used, inasmuch as it presents a resemblance to the sur- 
rounding healthy tissue. 

The same authors have entered into more special detail, however, 
and have described three varieties, the mammelonated, the partial, and 
the generalized. 

479. I. The mammelonated lobular pneumonia consists of a small 
nodule {noyau) of hepatization, quite distinct from the surrounding 
tissue ; it is an isolated point of disease, in the midst of healthy or 
nearly healthy tissue, with its limits clearly defined. The limits are 
occasionally marked by a white resisting circle or space, like a fibrous 
capsule ; and ordinarily we can define the extent of the diseased por- 
tion from its prominence, which results from the shrinking of the sur- 
rounding parts when cut through. 

The volume of these nodules varies from that of a hempseed to a 



328 INFLAMMATION OF THE LUNGS. — PNEUMONIA. 

pigeon's egg; their shape is generally regular and spherical, or some 
analogous form ; varying in number from one to twenty or thirty in the 
same lung. They result, it is clear, from the inflammation being limit- 
ed to one or more lobules, without extending to the neighboring tissue ; 
but in some few cases they are surrounded by a portion, in the first 
stage of pneumonia, just as we see in the case of tubercles. 

480. In these nodules of hepatization, it is not rare to find the dis- 
ease attain the third degree, and form an abcess. The pus primarily 
deposited in the pulmonary tissue is collected in the centre of the in- 
flamed lobule, surrounded by two concentric zones, the inner one of 
yellow color, the third degree of inflammation, and the outer one of a 
red color, inflammation of the second degree, or hepatization. By 
degrees the suppuration is increased, at the expense of the inner circle 
and of the outer, and the centre is surrounded by a layer of false mem- 
brane. If several lobules close to each other have been attached, the 
abscess may be multilocular, and each cavity separated from its neigh- 
bor by a thin layer of hepatized tissue : or, this being broken through, 
they will communicate with each other. 

These abscesses may be situated in any part of the lungs, but they 
have rather a tendency towards the surface, and we occasionally find an 
adhesion between the two pleurse at this point. If this adhesion do 
not take place, the abscess may open there, and a pneumo-thorax be the 
result. Rilliet and Barthez met one case in which adhesion took place 
between the pleura of the base of the left lung and the diaphragm, 
and through this adhesion the abscess opened into the peritoneal 
cavity. 

481. M. Barrier differs from the view taken by Rilliet and Barthez 
of these abscesses, but as I have not entered very minutely into their 
description, I shall avoid the controversy altogether, and simply quote 
M. Barrier's conclusion : " Lobular pneumonia may terminate by sup- 
puration in three ways: 1. Gray hepatization, when the pus is com- 
bined with and infiltrated into the parenchyma, constituting the most 
frequent and least advanced form. 2. Purulent collection in the lobule, 
with direct free communication with the corresponding lobular bronchus, 
which is dilated but not interrupted in its continuity, and which seems 
to widen in order to form the purulent cavity (vacuole). This is far 
from being rare, and is intimately connected with capillary bronchitis. 
3. Abscess, properly so called, or collections of pus, primitively iso- 
lated, and closed completely ; coronfcunicating at a later period with 
the bronchial tubes, by rupture of its walls. This form is really very 



rare. 



The number of abscesses varies very much ; sometimes there is but 
one, in other cases a great number. They are rarely found in both 
lungs, and most commonly in the left. Of twenty-six cases, Rilliet and 
Barthez found abscesses in seven cases, in the right lung, in fifteen cases 
in the left lung, and in four in both lungs. Eight of these cases occur- 
red in infants from one year to two and a half years old ; ten, from 
three to five and a half; three, from six to ten and a half; and four, 
from eleven to fifteen years of age. 

1 Mai. de l'Enfance, vol. i. p. 60. 



INFLAMMATION OF THE LUNGS. — PNEUMONIA. 329 

482. II. The partial lobular pneumonia is less defined than the mam- 
melonated; its circumference is confounded insensibly with the sur- 
rounding tissue, without our being able to decide upon its limits from 
the color or prominence. The volume of the diseased portion is often 
considerable, and its form irregular. The whole may be hepatized, or 
the outer portion congested and the centre hepatized ; and by the exten- 
sion of the inflammation, many separate points of disease maybe united, 
so as to involve nearly the entire lobe, and so constitute the generalized 
partial pneumonia. When the latter passes into the third degree of 
inflammation, it becomes, to all purposes, lobar pneumonia, and yet 
there is a considerable pathological difference. The three degrees of 
inflammation are evident in both, but they are disposed differently ; in 
the latter, commencing most generally at the base, and ascending, we 
shall find the lower portions the most advanced, and the superior less 
so; whereas, in generalized lobular pneumonia, the most advanced por- 
tions will be those of longest standing; and as the disease begins at 
different points, we may find gray hepatization in any part, and conges- 
tion or red hepatization occupying the spaces between. 

Abscess may be the result of this species of pneumonia, but less fre- 
quently than of the former. Still more rarely is it found with the lobar 
pneumonia, although such cases are on record. 

Out of 203 autopsies of lobular pneumonia, Rilliet and Barthez met 
with seventy of the mammelonated, 140 of the partial, and 104 of the 
generalized pneumonia. 

Thus it seems quite possible that capillary bronchitis (443) may run 
on into lobular pneumonia, and lobular pneumonia, by becoming genera- 
lized, into lobar pneumonia ; but is far from being a necessary transi- 
tion. 

483. Garnification. — There is another morbid condition which de- 
mands our attention. It has not been described by authors generally, 
although sufficiently frequent ; its existence was first noticed by M. 
Rufz, in his memoir. He states : " I have observed an alteration of 
the pulmonary tissue, which is certainly not hepatization, although I am 
quite ignorant of its symptomatic value. This condition is ordinarily 
found along the inferior border of the superior lobe ; it may also occupy 
all the middle lobe, or the circumference of the base of the inferior 
lobe, to the extent of from a line to half an inch in thickness. In these 
parts, the pulmonary tissue is collapsed, of a violet color, but with 
whitish patches, which circumscribe the lobules. There is no crepita- 
tion ; the air appears entirely expelled ; one would say that it was a 
portion of lung, which had not as yet been expanded by respiration. 
When detached it does not float ; it is firm, and when hepatization co- 
exists, it is not easy to perceive the difference at the first glance." 1 

When cut into, we find a red, smooth, resisting tissue, on pressure 
furnishing a sero-sanguineous fluid, free from air ; resembling a divided 
muscle in appearance ; hence the name. 

Thus, as to situation and form, it resembles each variety of hepati- 
zation ; but it differs in that insufflation restores it to its natural condi- 

1 Journ. des Connois. Med. Chir., 1835, 404. 



330 INFLAMMATION OP THE LUNGS. — PNEUMONIA. 

tion just as we find in atelectasis pulmonum, which it resembles much, 
although produced by different causes. 1 This peculiar condition is 
nearly as frequent in the right as in the left lung, and more frequently 
single than double ; the most common situation for it is on the left side, 
near the heart, and on the right side, in the middle lobe. 

Rilliet and Barthez observed forty-two cases of carnification ; sixteen 
double ; seventeen on the right side only ; and nine on the left. 2 

484. Grangene of the Lung. — This termination of inflammation is 
very rare in children. Rilliet and Barthez met with eleven cases ; 
Barrier does not mention the subject; and Dr. West has seen but one 
case. I shall quote Dr. West's description of the post-mortem appear- 
ances, as being as concise and accurate, and more vivid, than any I could 
give : " The right lung, which consisted only of two lobes, was univer- 
sally solid, and not crepitant, with the exception of about a fourth of 
the upper and inner edge of the upper lobe, which was emphysematous. 
The two lobes were connected together by a layer of yellow lymph. 
The exterior of the lung generally was of a dark reddish-gray color, 
with irregular patches of yellow deposit beneath the pleura, some of 
which were nearly half an inch in length and a quarter in breadth ; 
besides which, many small purulent deposits were contained within the 
pulmonary vesicles, as in vesicular bronchitis. The upper part of the 
upper lobe, and a small portion near the diaphragmatic surface of the 
lower lobe, felt soft and boggy to the touch. On cutting into the upper 
lobe, a cavity was opened as large as a hen's egg, very irregular in 
form, intersected in various directions by the tubes and vessels that 
crossed it, from which, as well as from the walls of the cavity, portions 
of the lung hung in shreds. The cavity contained a small quantity of 
dirty, grayish-yellow putrilage, which exhaled a most fetid odor. The 
substance of the lung in the immediate neighborhood was in a far ad- 
vanced stage of purulent infiltration, and other parts of the lobe were 
in an earlier stage of the same condition ; besides which, small collec- 
tions of puriform fluid, not bigger than a split pea, were found in vari- 
ous parts of its substance. The state of the lower lobe on the whole 
resembled that of the upper, but the cavity in its lower part was not 
larger than a marble, and contained a small quantity of yellow pus, of 
a less fetid character than that in the upper lobe. The bronchial glands 
were swollen, soft, of a homogeneous aspect, and a gray color ; but 
neither in them nor in either lung, nor in any organ of the body, was 
there the least trace of tubercular deposit." 3 

485. So much for the principal lesions of the lung resulting from or 
connected with pneumonia. I must just notice one or two others more 
or less frequently observed. 

I. Bronchitis. — Inflammation of the mucous membrane of the bronchi 
may be detected in the great majority of fatal cases of pneumonia, and 
especially of lobular pneumonia, from the earliest slight congestion, 
with increased secretion, up to entire vascularity, thickening and soft- 
ening of the mucous membrane, and dilatation of the tubes with puru- 

1 Archiv. fur Physiologische Heilkunde, 6th par. vol. iv. 

2 Mai. des Etifans, vol. i. p. 74. 

3 Lectures on Diseases of Infancy and Childhood, p. 209. 



INFLAMMATION OF THE LUNGS. — PNEUMONIA. 331 

lent or pseudo-membranous matter contained in them. Although the 
tubes connected with the diseased lobules are almost always affected, 
yet they are not invariably so, nor is the inflammation limited to these 
tubes. I have already given Rilliet and Barthez's conclusions from 
their experience. 

II. The pleura not unfrequently exhibits evidence of ancient or recent 
inflammation, more frequently the latter. Adhesions, false membranes, 
vascularity, and effusion, may one or all be observed in these cases of 
secondary pleuritis. M. Valleix met with them in twenty cases out of 
one hundred and twenty-three. 

in. The bronchial glands are often quite healthy ; in other cases, 
they are enlarged, softened, and red, or they may contain tubercular 
matter. Their alterations, however, are of no practical importance. 

iv. According to M. Barrier, in a small number of cases complicated 
with convulsions, traces of inflammation of the membranes of the brain 
were detected. In other similar cases, no such evidences were found. 

V. The intestinal canal may occasionally exhibit marks of irritation ; 
but although diarrhoea is a very common complication of secondary 
lobular pneumonia, it rarely, if ever, appears to be owing to inflamma- 
tion of the mucous membrane, except in cases complicated with muguet 
or tubercles. 1 

486. These, I believe, are all the morbid phenomena to be learned 
by a post-mortem investigation. The inquiry still remains as to what 
relation they bear to each other. Whether they are in truth a chain 
beginning with bronchitis and terminating at gangrene, or whether 
there is some difference in kind? Whether bronchitis invariably pre- 
cedes lobular pneumonia ? Whether every form of bronchitis may 
originate pneumonia, or what form has this peculiar consequence ? And 
why, if this be the result of any species, such an effect should be con- 
fined to the period of infancy ? 

M. Barrier has entered at length into these interesting questions, and 
has, I think, shown that all varieties of bronchitis do not equally give 
rise to pneumonia, but only the vesicular or capillary bronchitis ; that 
lobular pneumonia is almost invariably preceded by it, and that capil- 
lary bronchitis is more frequent from one to six years than at any other 
age; and that at this period the anatomical and physiological conditions 
of the respiratory organs are more favorable for the extension of inflam- 
mation to the substance of the lungs. But I will give his conclusions 
in his own words : " 1. The influence of age upon the production of 
lobular pneumonia is circumscribed within the period of from one to six 
years. Before and after that age, the disease is rare. 2. The ana- 
tomical and physiological conditions of the lung at that age are but 
secondary in the production of the lobular form of pneumonia. 3. 
Observation proves that the disease, in its development, is intimately 
connected with preceding bronchitis. 4. The species of bronchitis 
which has most influence is that which occupies the smaller tubes, and 
in which the catarrhal element is the most marked — it might be called 
catarrh of the small bronchi. 5. Lobular pneumonia is more frequent 

1 Valleix, Clinique des Mai. des Enfans, p. 70. 



332 INFLAMMATION OF THE LUNGS. — PNEUMONIA. 

from one to six years, because this catarrh of the small tubes is most 
frequent during the same period, and because it calls into action those 
anatomical and physiological peculiarities which diminish after that age. 

6. Inflammation attacks the lobules, either because it is propagated 
from the bronchi to the lobules by continuity of tissue, or from the 
stagnation of the mucus in the most dependent bronchial tubes. The 
obstacle resulting from this, to the penetration of air into the lobules, 
favors the sanguineous engorgement, as by a species of partial asphyxia. 

7. MM. Rilliet and Barthez have not understood all the importance of 
the bronchitic affection ; the opinion of MM. Burnet and De la Berge 
appears better founded, but it wanted the demonstration into which we 
have entered. 8. To pretend that it is not demonstrated that bronchitis 
always precedes pneumonia, and not the contrary, is to put forth a 
slightly founded objection, and one easily refuted. 9. If lobar pneu- 
monia is rare from one to six years, it is because the causes of this form 
are rarely in action at this age." 1 

Thus, then, it would appear that capillary bronchitis may become 
the first step towards pneumonia ; congestion follows, then hepatiza- 
tion, red and gray, abscess, and gangrene. So far the chain seems 
quite complete ; the disease may run through all its stages, or it may, 
of course, stop at any of them ; and experience shows us that the limit 
between capillary bronchitis and the first stage of pneumonia is very 
often intact. 

487. But in this series of morbid phenomena, what place is held by 
that condition of the lung which has been termed carnification f Is it 
the product of inflammation, a modification of hepatization, or is it a 
quasi-normal condition, as if that portion of lung had been exempt from 
respiration ? 

Rilliet and Barthez seem inclined to regard it as a kind of termination 
of pneumonia, or as a chronic pneumonia ; and they mention the case 
of a child, who for a long time presented the signs of pneumonia of the 
right lung, yet afterwards died of pneumonia of the left lung. On 
making the autopsy, a considerable carnification of the right lung was 
found occupying the situation of the auscultatory evidences of pneumonia 
during life. 2 

M. Barrier admits that it is not quite understood, but that it is pro- 
bably the consequence of acute inflammation, and " may be considered 
as a termination of induration." 3 

Hasse, in his Pathological Anatomy, regards it as a persistence of 
the foetal state of the lungs after birth, and distinguishes between this 
condition and inflammation. 

MM. Legendre and Bailly have described this state, and regarding 
it as passive and asthenic, and not active, and not pathological — a 
physical modification of the organ, analogous to the condition of the 
foetal lungs — they have founded upon this opinion an entirely new view 
of the disease termed lobular pneumonia. 4 

This condition of the lung they believe is not the result of inflamma- 

1 . Mai. de l'Enfance, vol. i. p. 98. 2 Mai. des Enfans, vol. i. p. 74. 

3 Mai. de l'Enfance, vol. i. p. 62. 

4 Archives Gen. de Med., Jan., Feb., and March, 1844. 



INFLAMMATION OP THE LUNGS. — PNEUMONIA. 333 

tion, but that the lung or portions of it collapse, owing to the congested 
or distended state of the capillaries, and assume this " Stat foetal," or 
" £tat foetal congestionnel." These portions they say differ from hepa- 
tized lung, inasmuch as they may be easily distended by air, and so re- 
stored to their primary state, whereas the hepatized lung is impermeable 
to air ; but in this they are opposed to the experience of M. Bouchut. 
According to these authors, therefore, lobular pneumonia is truly a pul- 
monary catarrh, answering pretty much to capillary bronchitis, with 
these collapsed portions of the lung reduced to a condition analogous 
to the foetal lung, or to that state which has been termed atelectasis. 

M. Friedleben differs from this view, and considers that the pneu- 
monia of children runs through the same course as that of adults, but 
that the lobar pneumonia is more frequent than has been supposed. 1 

Dr. Fuchs has carried further the theory of Legendre and Bailly. 
He states that he has never found a condition of the pulmonary paren- 
chyma at all analogous to that observed in the pneumonia of adults, 
and that the changes are not due to inflammation, but to the cells be- 
coming void of air and atrophied. To this condition he applies the 
term apneumatosis, and he thus describes the condition of the lung : 
"The apneumatic lung is in its first stage of a dark color, contains air, 
swims and crepitates ; its compass is less than that of a collapsed lung, 
and hence single lobules in the apneumatic condition appear as if sunk 
in the normal tissue. Inflation can be performed. In the second stage, 
the tissue becomes firm, compact, and void of air ; it assumes a uniform 
character, a small compass, has an even surface on division, and no 
longer permits of inflation. In the third, it appears as a blue-gray 
colored tissue with white streaks." Dr. Fuchs distinguishes between 
this morbid condition established after respiration ; and the foetal con- 
dition of the lungs before respiration, and whilst he admits that the first 
stage may come on as a pulmonary catarrh in very young children, in 
older ones it will have more the character of a determinate inflammation. 

Now let me observe that in this question there are two points involved 
— first, what is the true nature of that state of the lung which has been 
called carnification — is it the result of inflammation ? is it a modifica- 
tion of hepatization, or is it really a collapse or atrophy of the paren- 
chyma, the result of changes in the neighboring parts ? and secondly, if 
it be non-inflammatory and only a passive apneumatosis and atrophy, is 
it the principal or the only change observed in lobular pneumonia, and 
are we to infer that that disease is truly a capillary bronchitis with the 
addition of (or producing) this collapsed condition of the lung? I do 
not feel competent to decide these questions, but it appears to me that 
additional observations are required before we can agree with the origi- 
nal views of MM. Legendre and Bailly, West and Fuchs. 

I am, however, inclined to believe that bronchitis may result in either 
lobular pneumonia or atelectasis, but that probably atelectasis is often 
mistaken for lobular pneumonia, and further, the condition which has 
been termed carnification has greater resemblance to the latter than to 
the former disease. 

1 Arch, fur Physiologisehe Heilkunde, Part 2, 1847. 

2 Der Bronchitis, der Kinder, 1849. 



334 INFLAMMATION OF THE LUNGS. — PNEUMONIA. 

For further details on this subject I would refer my readers to Dr. 
Wiltshire's valuable and elaborate essay, Historic Data on Infantile 
Pneumonia, in which he has traced the succession of opinions and 
analyzed the views of the different authors with no small learning and 
ability. 1 

488. Causes. — Among the predisposing causes, age appears to exer- 
cise a considerable influence. It has been said that primary pneumonia 
never attacks infants under five years; but Rilliet and Barthez have 
shown that this is not true. Out of 245 cases, fifty-eight were primary, 
and of these twenty-four were under five years, i. e., five from one to 
two years, and nineteen from three to five; and thirty-four were beyond 
five years. Of these fifty-eight cases, fifty-five were lobar pneumonia. 

M. Valleix mentions that the age of his patients were, of simple 
pneumonia, from seven to twelve days ; of pneumonia with cedema, from 
two to eight days ; and of pneumonia with muguet, from nine to twenty 
days. 2 

M. Hache, out of 108 autopsies, found pneumonia in seventy-one 
between the ages of two and five, and in thirty- seven from five to fifteen 
years of age. 3 

M. Barrier, out of twenty cases of lobar pneumonia, met with three 
before the age of five years, six from five to eight, seven from eight to 
eleven, and four from eleven to fifteen. 4 Of sixty- one cases of lobular 
pneumonia, forty-five were between two and five years, and sixteen from 
five to sixteen. 

In 203 cases, Rilliet and Barthez found lobular pneumonia between 
the ages of one and five and a half in 160, and from six to fifteen in 
forty-three cases. 

Thus, both primary and secondary, both lobar and lobular pneumo- 
nia, may occur from birth up to fifteen years ; both are more frequent 
before five than after, but especially lobular pneumonia. 

489. The predominance of the male sex is more marked in lobar than 
in lobular, in primary than in secondary pneumonia. Of twenty-four 
cases of primary lobar pneumonia, referred to by Rilliet and Barthez, 
nineteen were males and five females; and of forty-five of secondary 
pneumonia (generally lobular), twenty-seven were males and eighteen 
females. Of sixteen cases of lobar pneumonia, related by Dr. Gerhard 
and M. Rufz, twelve were males and four females. Ten out of fifteen 
of M. Valleix's cases were males. Of M. Vernon's 114 cases, there was 
an equal number of males and females. Of 104 cases mentioned by 
Dr. Condie, sixty were boys and forty-four girls. Of 1615 deaths from 
pneumonia, occurring in Philadelphia during the ten years preceding 
1845, 872 were in boys and 743 in girls. 5 According to M. Barrier, 
sex asserts but little influence upon lobular pneumonia. 

Temperament and constitution, doubtless, exercise great influence in 
the production of the disease; those of a lymphatic temperament and 
of an enfeebled and broken-down constitution being peculiarly liable to 

1 British and Foreign Med.-Chir. Rev., Oct. 1853, p. 514. 

2 Clinique des Mai. des Enfans, p. 173. 3 Mai. des Enfans, p. 478. 

4 Mai. de l'Enfance, vol. i. p. 187. 5 Diseases of Children, p. 312. 



INFLAMMATION OF THE LUNGS. — PNEUMONIA. 335 

secondary and especially lobular pneumonia. Of 245 cases related by 
Rilliet and Barthez, only fifty-eight were stout and well when attacked; 
and in fifty-five of these fifty-eight, the form of disease was lobar pneu- 
monia; in a great majority of the remainder, it was lobular pneumonia. 

Dr. Stewart mentions an hereditary predisposition in some families 
to the disease. 1 

M. De la Berge and M. Leger state that the disease is more frequent 
in spring and autumn ; Dr. Gerhard, that primary pneumonia prevails 
in the months of April and May ; Rilliet and Barthez mention that from 
April to September, 1837, only six cases of primary pneumonia were 
received into hospital, whereas, in the same months of 1840, twenty- 
two were admitted. 

During the six summer months of the year referred to by M. Barrier, 
fifty-six cases of pneumonia occurred. 

So that we cannot regard the summer as conferring immunity from 
this disease; nevertheless, I have no doubt that in this country it will 
be found far more frequent during the winter. In this city, I have gene- 
rally met with more cases from December to the end of March than at 
any other period of the year. This is confirmed by the opinion of Dr. 
Stewart and others; and Dr. Hood has quoted from Mr. Chadwick the 
following details : In winter there were 3326 cases of pneumonia ; in 
spring, 2454 ; in summer, 1827 ; and in autumn, 3600. 

490. No doubt that cold is the most frequent exciting cause among 
children ; it can hardly affect young infants so much, but yet they are 
often exposed. Change of room, change of garment, exposure to 
draughts of air, going out in unsuitable weather, the prevalence of 
damp, and certain winds, all may excite the disease even in the most 
healthy, how much more in those already weakened by disease. 

By certain French writers, much stress has been laid upon the effect 
of a prolonged dorsal decubitus in the production of the disease among 
the children in the Hopital des Enfans at Paris. MM. Billard, Denis, 
De Commercy, Leger, Rilliet and Barthez, all attribute more or less 
influence to this cause ; but it seems probable that at least as much is 
owing to other causes acting at the same time. 

Pneumonia may also prevail epidemically, or, what is more frequent 
in this country, it may form part, as it were, of the epidemic influenza, 
sometimes the bronchitic, at others of the pneumonic element prevail- 
ing, as I noticed in the last chapter. 

Dr. Cheyne mentions that it prevailed epidemically every winter, 
about Leith — in the years 1802, 3, 4, and 8, he had seldom less than 
from 15 to 30 cases under his care. 2 

491. Dr. West has given definite numbers for a fact which all must 
have experienced with regard to pneumonia, I mean the great liability 
of those who have once suffered from it to be again attacked. Of sev- 
enty-eight cases which came under Dr. West's care for inflammation of 
the lungs, " thirty-one were stated to have had previous attacks of the 
disease ; twenty-one, once ; four, twice ; two, four times ; and four were 
said to have had it several times, though the exact number of seizures 

1 Diseases of Children, p. 50. 2 Pathology of Larynx and Bronchia, p. 187. 



836 INFLAMMATION OF THE LUNGS. — PNEUMONIA. 

was not mentioned. Of these thirty-one, ten were under two years of 
age ; ten, between two and three ; and the remaining eleven, between 
three and six.'' 1 

492. We must now examine as to what diseases predispose to pneu- 
monia, as a secondary affection, and I shall avail myself of a table 
drawn up by my friend Dr. West. It concerns 166 cases, and of these, 

" In sixty-five cases, the respiratory organs presented no sign of 
recent inflammation, the children having died of the following dis- 
eases : Of trismus, three ; meningeal apoplexy, two ; cerebral conges- 
tion, one; inflammation of the brain, one; acute hydrocephalus, twenty- 
five ; cerebro-spinal arachnitis, three ; chronic hydrocephalus, one ; 
tubercle of the brain, three; cancer of the brain, one; croup, two; 
laryngismus stridulus, two; phthisis, five; anasarca, one; anasarca 
after scarlet fever, one; diarrhoea, four ; atrophy, three; congenital 
syphilis, one; cancrum oris, two; lumbar abscess, one; scrofulous dis- 
ease of the vertebrae, one ; fungus nematodes of the liver, one ; of the 
kidney, one. 

" In fourteen cases, though there was no sign of inflammation, yet a 
more or less considerable portion of the lung was collapsed, but restored 
by inflation to its natural condition, or presented the physical charac- 
ters of collapsed lung in so marked a degree as to preclude the possi- 
bility of error. The causes of death in these fourteen cases were : — 
congenital atelectasis, one ; induration of the cellular tissue, one ; con- 
vulsions, one ; meningitis of the convexity of the brain, one ; conges- 
tion of the brain occurring in the course of hooping-cough, one; tubercle 
of the brain, one ; atrophy of one hemisphere of the cerebellum, one; 
atrophy, five; laryngismus stridulus, one; fungus hsematodes of the 
kidney, one. 

" In forty-seven of the above seventy-nine cases, the pulmonary tis- 
sue was quite free from tubercle. In twenty-two, the lungs contained 
crude tubercle only ; in three, some softened tubercles. 

"In the remaining eighty-seven cases, either the pulmonary sub- 
stance, the bronchi, or the pleura, showed signs of recent inflammation. 

" The pleura was mainly affected in twelve of these cases, its inflam- 
mation having been idiopathic only in four. In six of these cases the 
lung was inflamed ; in the other six, merely compressed. 

" In nineteen cases the inflammation was chiefly or entirely confined 
to the bronchi, and in six of these the inflammation was idiopathic. 

" In fifty-six cases pneumonia prevailed, which was idiopathic in sev- 
enteen, and secondary in forty-five instances. 

" In the fifty-nine cases of acute secondary inflammation of the lungs 
or bronchi, the patients had suffered from the following diseases 
Hooping-cough, sixteen; phthisis, seven; acute pleurisy, six; measles 
five; croup, three; scarlatina, three; diarrhoea, three; acute hydro 
cephalus, three; croup, consequent on measles, two; remittent fever 
two ; acute meningitis, two ; chronic bronchitis, one ; coryza, one ; ana 
sarca after scarlatina, one ; cancrum oris after remittent fever, one 
acute rheumatism, one ; convulsions, one. 

1 Lectures cm Diseases of Children, p. 180, note. 



INFLAMMATION OP THE LUNGS. — PNEUMONIA. 337 

" Of the whole eighty-seven cases ; in sixty-nine the pulmonary tissue 
was free from tubercle ; in ten, it contained tubercle unsoftened ; in 
five, tubercle softened; in three, tubercular cavities." 1 

This valuable summary affords both negative and positive informa- 
tion ; negative as to the diseases of which pneumonia is not a frequent 
complication, and jaositive, as to those in the course of which it occurs 
as a secondary attack. However, as Dr. West observes, it would re- 
quire a large number of cases to enable us to draw any stringent con- 
clusions. So far as it goes, it confirms pretty exactly what I have said 
previously. 

493. According to M. Barrier, of sixteen cases, thirteen were con- 
nected with acute catarrh, and three with chronic catarrh, occurring in 
the course of measles ; in two, with scarlatina ; in three, but obscurely, 
with smallpox; in ten, with bronchial catarrh ; in twelve, with bronchial 
and intestinal catarrh ; in nine, with hooping-cough ; in one, with 
typhoid fever. 

There can be little doubt that lobular pneumonia arises most fre- 
quently in the course of the eruptive fevers, bronchitis, and hooping- 
cough ; and knowing this, it is our duty to be constantly on the watch, 
that Ave may detect the earliest symptom. 

494. Diagnosis. — The diagnosis of the lobar form is less difficult than 
of lobular pneumonia ; we have the short cough, pain in the chest, hur- 
ried breathing, dulness on percussion, crepitant r&le, and fever. In 
lobular pneumonia, the cough, dyspnoea, and fever, are much the same, 
the pain is less, and the dulness on percussion not so perceptible in the 
mammelonated form of the disease. In the generalized form we shall 
have less difficulty, as the dulness is marked, and the crepitant or sub- 
crepitant rale very evident. 

I. The differential diagnosis between this disease and bronchitis will 
depend very much upon the clearness on percussion, the presence of 
mucous and sibilant rales, the absence of the crepitating or sub-crepi- 
tating rales. In the latter disease, the face has generally a purplish 
tinge, the cough has more of a kink, the respiration is more labored, 
and perhaps less hurried. 

II. From 'pleurisy. In both, of course, there is dulness on percus- 
sion, spreading rapidly ; but in general there is less constitutional and 
local disturbance in pleurisy, the cough is not so frequent, the pulse not 
so quick, nor is there the same hurry of breathing. The pain in pleurisy, 
also, is more distinct, severe, and occupies a different situation. The 
distinguishing characteristic rales of pneumonia are, of course, alto- 
gether absent, and the vocal sound may be different. 

III. There may be great difficulty in distinguishing pneumonia from 
a sudden infiltration of tubercles. M. Grisolle remarks : " A child 
has a hot skin, violent fever, dulness, with bronchial respiration under 
one of the clavicles, and we have no information as to its previous his- 
tory. Is it certain, then, as Rilliet and Barthez ask, that the child has 
pneumonia ? These physicians have often seen this question answered 
in the affirmative, and treated accordingly, and yet the autopsy has 

1 Lectures on Diseases of Infancy and Childhood, p. 181. 



338 INFLAMMATION OE THE LUNGS. — PNEUMONIA. 

proved that these symptoms depended upon a tubercular infiltration of 
the lung. "In such cases," they remark, "we must observe the in- 
tensity of the fever, and especially the cause of the disease ; if the 
stethoscopic phenomena persist, notwithstanding the diminution of the 
general symptoms, it is probable that this persistence is the conse- 
quence of the tubercles. I am completely of the opinion, but this 
does not prove that the fever and bronchial respiration may not have 
been owing to a kind of pneumonia.'' 1 

495. Prognosis. — Primary pneumonia, whether lobar or lobular, is 
much less fatal than the secondary disease. Lobar pneumonia (per- 
haps because more frequently primary) is less fatal than lobular, and 
uncomplicated much less fatal than when complicated. Secondary 
lobular pneumonia is, of course, frequently fatal, partly owing to the 
disease itself, but much more to the effects of the primary malady, 
and the inability of the child's constitution to resist the inroads of a 
new disease. 

Of twenty-one cases of primary pneumonia, Billiet and Barthez state 
that twenty-one were cured. Of twenty cases of lobar pneumonia, 
according to M. Barrier, but one died ; whilst, of sixty-one cases of 
lobular pneumonia, forty-eight died, eight were completely, and five 
incompletely cured. 

496. Treatment. — Before entering upon the treatment of any case of 
pneumonia, we should carefully satisfy ourselves whether it be primary 
or secondary, whether simple or complicated, and of the exact state of 
any other existing malady, whether primary or secondary, and of the 
state of the patient's constitution, its strength or weakness, the injury 
already done to it, and the probable powers of endurance remaining. 
This done, we may select and apportion the remedies at our command, 
which, although few and simple, do yet require judgment in their ap- 
plication. The principal remedies are bleeding, tartar emetic, calomel, 
counter-irritation, and stimulants. 

It will be also essential to remove all existing causes of irritation, 
and amongst these the most influential is probably that arising from 
dentition. Whether it may give rise to pneumonia or not, certain it is 
that it will increase and perpetuate the inflammatory action. In all 
children, therefore, at the age of teething, the gums should be exa- 
mined, and if the gums be at all swollen or inflamed, they should be 
divided thoroughly. 

497. I. Bleeding, either generally or locally, is one of our most pow- 
erful means for arresting inflammation of the lungs. Some of the con- 
tinental writers object to it, as weakening the patient, but, as Dr. West 
observes, this opinion, being formed from the cases of secondary pneu- 
monia met with in the hospitals, cannot be a guide to us in general 
practice. 

The great majority of British and American practitioners agree in 
recommending that at the commencement of pneumonia blood should be 
freely abstracted, according to the age and strength of the patient, and 
that, if it be necessary, owing to the severity and obstinacy of the dis- 

1 Traite de la Pneumonie, p. 513. 



INFLAMMATION OF THE LUNGS. — PNEUMONIA. 339 

ease, it should be repeated once or twice. The blood may be taken 
from the arm of the child, if it be old enough, or by cupping or leeches 
to the chest, hand, or foot. I prefer leeches to the chest in infants, 
because they are more manageable, and less likely to frighten a young 
child than cupping ; and I think they produce greater effect when ap- 
plied to the chest than to more distant parts. 

Both lobar and lobular pneumonia may be thus treated freely when 
primary, but when secondary it will be necessary in all cases to modify 
the amount taken; and in some eases, when the child is much broken 
down and exhausted, it would be very imprudent to take blood at all. 
In such cases we must have recourse to counter-irritation, calomel, or 
perhaps tartar emetic. " When an abundant effusion has taken place 
into the bronchia," Dr. Cuming observes, in his excellent paper, " and 
when, as generally happens, this state is combined with more or less of 
collapse of the system, the abstraction of even a very trifling quantity 
of blood might be attended with a fatal prostration." 1 

When the leeches have ceased bleeding, a large, soft, warm poultice 
of bread and milk or linseed-meal should be constantly applied to the 
part affected. I have found nothing afford such immediate comfort and 
relief to infants and children. It may be removed when counter-irri- 
tants are to be applied, and then replaced. It soothes the sensations, 
relieves the aching pain, quickens the action of the counter-irritants, 
and promotes expectoration. 

498. ii. Tartar Emetic. — No physician is ignorant of the extreme 
value of tartarized antimony in the treatment of pneumonia in the adult. 
It is not less valuable with children, but it requires a little more watch- 
fulness and caution, as it sometimes produces very alarming depression. 

After bleeding, in all primary cases, it will be right to give it a fair 
trial, and, if it acts kindly, to continue it as long as we find necessary. 
The dose must be graduated according to the age of the child, the object 
being rather to produce nausea than vomiting. It will often be found, 
however, that a child will bear a larger dose than we might suppose, 
and that, although the first dose may cause vomiting, the subsequent 
ones will not. Or we may commence by producing vomiting, and then 
diminish the dose, so as to occasion nausea merely. Dr. West recom- 
mends " one-eighth of a grain every ten minutes, till vomiting is pro- 
duced, in the case of a child two years old, and continued every hour 
or two afterwards, for twenty-four or thirty-six hours." 

One grain of the salt to two ounces of fluid for a child under two 
years, and two grains for a child of four or five, will form a mixture of 
which a teaspoonful may be taken every two, three, or four hours. The 
following mixture answers the purpose, and, besides being very palata- 
ble, will probably check the tendency of the tartar emetic to act on 
the bowels: — 

R.— Mist, amygdal. gij. 

Antim. tartarizati, gr. j. vel ij. 
Syr. papav. alb. 31J. — M. 
A teaspoonful to be given every three or four hoiu*3. 



1 Trans, of Association, vol. 



340 INFLAMMATION OP THE LUNGS. — PNEUMONIA. 

But in secondary pneumonia, when the patient is much reduced espe- 
cially, or when the stomach and intestinal canal have been affected, we 
must be very cautious how we give tartar emetic. 

If used at all, it must be given in much smaller doses, at the same or 
longer intervals, or we may seriously aggravate the patient's weakness, 
or add to the intestinal irritation. 

If we cannot give it, our great reliance must then be upon calomel, 
counter-irritation, and stimulants. 

499. III. Calomel. — It is rarely advisable or necessary to give calo- 
mel so long as we are employing tartar emetic ; but when a change 
becomes desirable, or for any reason we are afraid to give the latter 
medicine, we must have recourse to calomel. Of less immediate value, 
perhaps, than tartar emetic, it is still of great importance, and pos- 
sesses great control over inflammatory action. 

It may be given in doses varying from one-fourth or one-third of a 
grain to a grain, every three, four, or six hours, guarded by a little 
Dover's powder, or the powder of chalk with opium. 

In secondary pneumonia it will still be found of great use, provided 
there be no diarrhoea, or provided we can so guard it as to prevent it 
acting upon the bowels. Sometimes the hyd. c. creta is better borne 
than calomel, though less effective. 

If we cannot give it, on account of the state of the bowels, we may 
use mercurial inunction, which has more effect with children than adults, 
from the greater sensitiveness of their skin. 

Although salivation or ulceration of the gums are very rare in chil- 
dren under five years of age, yet, as they do occasionally occur, it is 
necessary to watch the child, and to stop the mercury on the first sign 
of tenderness of these parts. 

500. iv. Counter-irritation. — I have always derived great benefit 
from blisters in pneumonia, provided they were not applied too soon. 
We ought not to apply them during the height of the fever, until after 
having recourse to bleeding and tartar emetic, except in cases in which 
these remedies have not been suitable. 

But after bleeding and tartar emetic have lowered the febrile excite- 
ment, even though the pulse still remains quicker than natural, a mode- 
rate-sized blister, applied for a few hours only over the seat of the dis- 
ease, will seldom fail to afford relief. It is better to apply it for a short 
time, and allow it to heal, and then apply another near to the former, 
than to cover the ehest with one at once. 

In cases where more active measures are inadmissible, a succession of 
blisters must be substituted, care being taken that they are not applied 
too long, so as to give rise to ulceration. 

Dr. West speaks highly of stimulating liniments, others of mustard 
plasters ; but, though useful, they are far less efficacious than blisters, 
and if the blister be carefully attended, I have not found any mischief 
result. 

When we do not give tartar emetic, or after we discontinue it, it will 
ibe necessary to give some cough mixture, and I have found one com- 
posed of equal parts of decoction of senega and water, with syrup of 



PLEURISY. — PLEURITIS. 341 

smilax and a little ipecacuanha wine, of great use, to which we may 
add the carbonate of ammonia towards the end of the disease, as thus : — 

R. — Decoct, senegse, gij. 

Carb. aramon. Qj. to gj. 
Vini ipecac, gss. 
Syr. smilac. a?p. sjiv.— M. 
Aqute, gij. 
A teaspoonful every three or four bours. 

501. v. Stimulants. — These are only required in cachectic cases, when 
the constitution has been broken down, or towards the termination of 
the disease, when the pulse has become slower, and the patient is 
weak. 

Ammonia is probably the best we can employ, and it may be given 
in almond milk, in doses of from half a grain to two grains every 
three or four hours, or it may be combined with the expectorant mix- 
ture. 

Under similar circumstances it may be necessary to give wine whey, 
or plain wine and water. 

A warm bath at the beginning of the disease, with fomentations to 
the feet occasionally, will be both soothing to the patient and benefi- 
cial. 

The diet in primary pneumonia must be low and spare, but towards 
the termination, and in all cases of secondary pneumonia, we shall 
find it necessary to support the strength by chicken broth, beef tea, &c. 

The bowels must be kept free, and it is well not to place the child 
always in one position in bed. 

502. During convalescence, the utmost caution and care must be 
exercised. The child should be confined to one room, or to two of the 
same temperature. For some time the clothing should be warm, with 
a light flannel waistcoat next the skin. 

For the treatment of the complications, I must refer the reader to 
the chapter on those diseases, merely observing that, although they 
much increase the danger, they often diminish our poAver of active treat- 
ment, and in some cases (as intestinal irritation) exclude some of the 
most valuable remedies for pneumonia. 



CHAPTER VIII. 

PLEURISY. — PLEURITIS. 

503. Inflammation of the pleura, or pleuritis, may attack children 
of all ages, although its comparative frequency varies a good deal. Of 
4012 patients treated at the London Infirmary for Children during the 
year 1846, only three cases of pleurisy 1 were noted; but out of 4158 

1 Eeport of the Royal Infirmary for the year 1846. 



342 PLEURISY. — PLEURITIS. 

admitted in 1845 to the Royal Institution for Diseases of Children in 
the district of Wieden, Vienna, there were seventy-six cases of the dis- 
ease. 1 "In London, during the year 1843-44, the deaths from pleurisy 
in children under fifteen years of age amounted to one-sixth of the whole 
number of deaths from the same cause ; 2 and of twenty-five deaths afc 
all ages, from pleurisy, registered in the month of January, 1847, 3 
eleven occurred under the age of fifteen years." 4 

M. Billard 5 states that he has found it more common than one would 
have expected ; and, on the other hand, M. Valleix considers it rather 
rare. 6 

Of 3392 autopsies of children under two years old, M. Baron found 
pleurisy in 205, or six per cent.; and of 181 autopsies of children from 
2 to 15, the pleura of 158, or eighty-seven per cent, was affected. 7 

Dr. Eberle' regards it as more common than is supposed. 

Mr. Crisp met with six cases of pleurisy in forty-one autopsies of 
children under two years of age. 8 Dr. Battersby has recorded six cases 
of simple or complicated pleurisy. 9 

MM. Ftilliet and Barthez have recorded eighty-five cases of pleurisy 
under fifteen years of age. 

M. Hache states that he has met traces of pleurisy in eighty-one 
cases out of 194 post-mortem examinations ; and M. Barrier has given 
fourteen cases. 

Erom these facts we may infer that pleurisy is not so rare a disease 
in children as many have supposed. Perhaps, indeed, this supposition 
may be the cause why so little attention was paid to the subject until 
lately. It is only recently that any very accurate researches have been 
undertaken into the distinction between pneumonia and pleurisy in 
children. We are indebted to Meissner, Henke, and Heyfelder, 10 in 
Germany; to Billard, Constant, 11 Baron, 12 Berton, 13 Rilliet and Barthez, 
and Barrier, in France; to Crisp, 14 West, and Battersby, 15 in these 
countries ; and to Stewart, Eberle', Condie, and Meigs, in America, for 
the principal information we possess. 

504. Symptoms. — Pleurisy may be either primary or secondary, 
simple or complicated, acute or chronic. It will be found to be modified 
somewhat in early infancy. Billiet and Barthez have also described 
the disease occurring in children of a broken down constitution under 
the name cachectic pleurisy. 

505. Primary Acute Pleurisy commences generally with depression 
and loss of appetite, occasional vomiting, weakness, slight cough, and 
a degree of fever, which subsides after a time. In some cases there are 
rigors ; in all the child seems ill, uneasy, and cross. In other cases 

1 Jahrbericht iiber die Leistungen des Unentzeldlischen Kinderkranken Instituts, &c. 

2 Sixth Annual Report of Ptegistrar-General. 

3 Weekly Tables of Births, &c, January, 1847. 

4 Dr. Battersby, Dublin Journal, Nov. 1847, p. 349. 

5 Mai. des Enfans Nouveaux-nes, p. 529. 6 Clinique des Mai. des Enfans, p. 198. 
7 De la Pleuresie dans l'Enfance. 8 London Med. Gaz., Dec. 25, 1846. 

9 Dublin Journal, November, 1847. I0 Archives, third series, vol. v. p. 59. 

11 Gazette Med., 1836, p. 265. Lancette, 1837, p. 146. 
' 2 Thesis, 1841. 13 Traite des Mai. des Enfans. 

14 London Med. Gazette, Dec. 25, 1846. 15 Dublin Journal, Nov. 1847, p. 348. 



PLEURISY. — PLEURITIS. 343 

the symptoms which usher in the disease are more alarming, and point 
rather to the head than the chest. " The child is seized with vomiting, 
attended with fever and intense headache ; it either cries aloud oris 
delirious at night, or screams much in its sleep, and, when morning 
comes, complains much of its head, but denies having any pain what- 
ever in its chest, while the short cough and hurried breathing may be 
thought to be merely the result of the cerebral disturbance." 1 

Early in the complaint, the child complains of pain in the side (gene- 
rally the left) if it be old enough ; in young children it is not always 
easy to ascertain this, except, perhaps, by the cry, when the side is 
percussed. 

The cough soon becomes troublesome ; it is short, dry, and inter- 
rupted, the respiration hurried and short, especially on lying down, 
because of the pain caused by deep breathing. Rilliet and Barthez 
consider the dyspnoea to be less than in pneumonia. "Respiration," 
says Dr. Condie, "is performed chiefly by the action of the abdominal 
muscles and diaphragm, the motions of the chest being instinctively 
restrained by the patient, in consequence of the pain attendant upon 
the elevation of the ribs ; sometimes each inspiration gives rise to a 
sharp cry or moan, and an expression of countenance indicative of 
suffering." 2 

In the majority of cases there is no expectoration, and when present, 
it is not peculiar. 

Mr. Crisp has noticed the throwing back of the head, and fixing it 
steadily there, as a peculiarity in pleuritis, and the distress occasioned 
by an attempt to straighten it. 3 

Dr. Battersby states that he has long observed it, and he thinks it 
arises " from an instinctive effort to avoid painful motion of the chest, 
by fixing the ribs, and giving full play to the abdominal respiration. 
This position of the head in pleuritis may be distinguished from that 
attending cerebro-spinal arachnitis, or other affections of the nervous 
centres, by all change of posture being followed by great uneasiness 
and screaming, while in the latter the infant is not so restless, nor 
crying so constantly, especially when moved or held erect, as in pleu- 
ritis." 4 

This fixing of the head backward occurs in pericarditis also, and in 
other affections ; and I must confess I have hitherto been unable to 
satisfy myself of its exact value as a symptom. 

The face is generally pale and anxious, with considerable contrac- 
tion of the respiratory muscles of the face, and action of the abe nasi, 
especially at the commencement. The tongue is moist, white, and 
loaded, the appetite impaired or lost. Vomiting occasionally occurs ; 
and the bowels, at first unaffected, are often subsequently attacked by 
diarrhoea. 

The decubitus is of little or no value in young children, as they gene- 
rally lie as they are placed in bed. In older children, one side or the 

1 Dr. West's Lectures, p. 213. 2 Diseases of Children, p. 290. 

3 London Med. Gazette, Dec. 25, 1846, p. 1104. 

4 Dublin Journal, Nov., 1847, p. 371. 



314 PLEURISY. — PLEURITIS. 

other will afford more ease. Dr. Stokes says on the healthy side in the 
beginning and the diseased side towards the end. 

The pulse is very quick at first, from 110 to 120, but it frequently 
subsides after a time to somewhat above the natural standard. At first, 
too, there is smart fever, with heat of skin, thirst, &c; but this very 
commonly diminishes. 

506. Now let us examine into the physical signs of pleurisy. At an 
early stage of the disease, we find the respiratory murmur enfeebled, 
and gradually retreating upwards as the effusion increases. Then we 
may detect bronchial respiration, generally constant, but occasionally 
disappearing and returning at intervals, owing, M. Bouchut thinks, 
either to the short inspirations or the interruption to the passage of air 
offered by the accumulation of mucus. MM. Rilliet and Barthez class 
this among the earliest symptoms of pleurisy; they found it present on 
the first, second, or third day. The sound in pleurisy is peculiar and 
metallic in its tone, differing in that and in its progress and duration 
from the bronchial souffle of pneumonia. Generally speaking, it is 
heard posteriorly, and at an early period, over the whole upper portion; 
at a later period, chiefly about the inferior angle of the scapula or the 
interscapular space. It lasts for some little time, and then disappears 
in the course of one, two, or three days ; or it may persist longer, and 
be audible either during inspiration or during both inspiration and 
expiration. 

When the case is simple and the termination fatal, it may be heard 
until the end. Rilliet and Barthez heard it after the twenty-seventh 
day, in a child who died on the twenty-eighth. But when the disease 
subsides, the bronchial souffle is superseded by feeble respiratory mur- 
mur, more rarely by frottement, and sometimes by pure respiration. In 
some few cases, this peculiar characteristic is absent. 

Rilliet and Barthez explain the frequency of the bronchial souffle by, 
1. The comparatively greater narrowness of the chest in children than 
in adults ; 2. The greater number of respiratory movements ; and 3. 
In certain cases, the small amount of effusion. 1 

Frottement, which is so characteristic a symptom of the early stage 
of pleurisy in adults, is comparatively rare in children. Both MM. 
Baron and Rilliet and Barthez agree that, though rare at the begin- 
ning, it is often present during the resorption of the effused fluid. The 
latter authors have never heard it in children under five years of age. 
Mr. Crisp, however, speaks of its occurrence in all his cases. 

Bronchophony and ego-phony occasionally accompany the pleurisy of 
children — the latter generally in the early stage in acute cases. It is 
heard ordinarily at the posterior and inferior part of the chest. It is 
more distinct in older children, though audible at all ages. When it is 
not present in very young children, there is generally a peculiar reso- 
nance of the voice. 

Percussion affords evidence of great value at the commencement of 
the disease. The dulness may be somewhat obscure, but as the disease 
advances it becomes more marked, keeping pace with the feebleness of 

1 Mai. des Enfans, vol. i. p. 149. 



PLEURISY. — PLEURITIS. 345 

respiration and the bronchial souffle, until at length the side of the chest 
becomes absolutely dull. This lasts until the disease begins to subside, 
and marks not only the locality but the duration, according to its per- 
sistence. By degrees, as the bronchial respiration is replaced by the 
feeble or pure respiration, the chest becomes more sonorous, and at 
length perfectly clear. 

As in the adult, change of position will modify the results of percus- 
sion as well as of auscultation. 

Taupin, 1 Baron, Rilliet and Barthez, Trousseau, and Bouchut, lay 
great stress on the absence of vibration when the effusion is consider- 
able, as was first noticed by Reynaud, Hudson, and Stokes. M. Bouchut 
conceives that this sign alone distinguishes it from all other inflamma- 
tions. If the hand be placed on the chest of a healthy person, we feel 
a remarkable vibration both of the respiration and voice; but if there 
be effusion, there will be no vibration perceptible, either from the respi- 
ration or the voice; and this is exactly the opposite of what we find in 
pneumonia. 

Dr. Stokes, however, mentions that it is inapplicable to many cases 
of boys and girls, before the change of voice, on account of the natural 
feebleness of the vocal vibrations. 2 Dr. Battersby thinks it impossible 
to detect this vibration before the eighth year. 

On inspection of the chest, the affected side appears immovable dur- 
ing respiration ; there is no expansion, no movement of the ribs. 

The measurement of the chest is by no means easy with infants and 
young children, nor does it yield much information early in the com- 
plaint, nor when it runs its course rapidly. When the attack is pro- 
longed several weeks, there is a notable difference in the two sides of 
the chest, in proportion to the effusion. The affected side is enlarged, 
the intercostal spaces are raised to the level of the ribs, or even pro- 
truded so that the ribs are not quite visible, and neither the sternum 
nor spine occupies the centre of the chest. When the fluid is absorbed, 
the affected side is contracted, but not to any great extent. 

It is very remarkable that neither Baron, Rilliet and Barthez, nor 
Barrier, have met with effusion so considerable as to displace the heart. 
M. Heyfelder has observed in chronic pleurisy considerable deformity, 
with curvature of the spine, and a displacement of the heart from its 
ordinary position. My very intelligent friend, Dr. Battersby, has re- 
lated four such cases, 3 and I have seen several. 

Thus, although the rational signs of pleurisy are not very clear, "we 
can hardly mistake the physical signs. In the earlier stage, feebleness 
of respiration, succeeded by the bronchial souffle, with marked and in- 
creasing dulness on percussion, absence of vibration in the side affected, 
perhaps egophony or vocal resonance, and at a later period, if the effu- 
sion be great, dilatation of the chest and dislocation of the heart. 

507. When pleurisy attacks an infant at the breast, the symptoms 
are necessarily more obscure, and the physical signs less readily ascer- 
tained ; there is fever, quick breathing, and cough, but whether pain or 

1 Recherches sin- le Dingnostique des Mai. de Poitrine chez les Enfans. 

2 Diseases of the Chest, p. 498. 

3 Dublin Journal, November, 1847, p. 353. 



346 PLEURISY. — PLEURITIS. 

not it is not easy to determine, unless we infer it from the child crying 
when the cough is troublesome. The infant is evidently very ill ; it 
sucks less eagerly, is fretful and heavy, and as the disease advances it 
loses its appetite; is sometimes attacked by diarrhoea ; the fever is occa- 
sionally remittent, with nocturnal exacerbations; the respiration is 
quick, hurried, and panting, and the cough frequent. 

The usual physical signs are present ; feeble respiration, bronchial 
respiration, dulness on percussion, except just at the beginning, and the 
absence of vibration when the hand is placed on the affected side. 

508. Acute Secondary Pleurisy may occur in the course of any other 
disease, but it seems peculiarly apt to develop itself in the progress of 
pneumonia, either from contiguity of structure or in consequence of the 
opening of an abscess (480) into the pleural cavity. 

The symptoms which mark its commencement vary a good deal ; it 
may begin in young children by convulsions or by sudden orthopncea. 
More frequently it commences with sudden and severe pain, with in- 
creased difficulty of breathing, and cough. The hurry of breathing and 
the rapidity of the pulse are often very great. 

The physical signs are somewhat modified, and in the case of pleurisy 
supervening on pneumonia have been thus stated by Rilliet and Bar- 
thez : "When effusion is superadded to pneumonia, it happens occa- 
sionally, but very rarely, that there is a complete absence of the respi- 
ratory murmur instead of bronchial respiration. Ordinarily the souffle 
is considerably increased in intensity ; sometimes it has even a cavern- 
ous tone, and if there be any mucus agitated by the rush of air, giving 
rise to a raile, one might mistake so far as to fancy that a cavity had 
been formed in the lung. At the same time the voice sounds so shrill 
that it is literally painful to the ear. If we percuss the chest, the dul- 
ness is absolute, whereas, a short time before, it was but relatively dull. 
We lay it down, then, as a principle, that tohen a pleuritic effusion su- 
pervenes in a child laboring under hepatization of the posterior part of 
the lung, all the abnormal sounds which were perceptible in the diseased 
part are considerably exaggerated, and the resonance on percussion lost." 1 

This peculiarity, however, is not observable in all cases ; it requires 
for its production that the hepatization should be sufficient to prevent 
the compression of the lung ; so that if a complete absence of the respi- 
ratory murmur succeeds to the symptoms of pneumonia, we may infer 
that the hepatization is neither extensive nor profound ; but, on the 
other hand, if the souffle, the resonance of the voice, and the dulness, 
are suddenly exaggerated, it is an evidence that the pneumonia was 
deep and extensive. 

509. Very frequently the progress of the disease is much more rapid 
than in simple pleurisy ; in other cases the duration may be more or 
less prolonged. In favorable cases, the symptoms gradually diminish, 
both locally and generally ; but in fatal cases they increase, and the 
smallness and feebleness of the pulse, the coldness of the extremities, 
paleness of face, and general sinking of the powers of life, warn us of 
the final result. 

1 Mai. des Enfans, vol. i. p. 152. 



PLEURISY. — PLEURITIS. 347 

But either primary or secondary pleurisy may pass into the chronic 
form. 

510. Chronic Pleurisy may either be the issue of an acute attack, or 
the disease may assume this form from the beginning. In the former 
case the symptoms gradually diminish to a certain point, but not beyond, 
the fever continuing more or less, but especially in the evening. 

In the second the symptoms are much more indefinite, and steal on 
insidiously. There may be little or no fever, the pain is uncertain, and 
not limited to one particular spot, or there may be none at all. The 
cough is slight, and at first there is but little distress in respiration ; 
the effusion, however, increases, the respiratory murmur is feeble or 
absent ; there is occasionally the bronchial soufflet, with marked dulness 
on percussion, and absence of vibration. 

On inspecting the chest when the effusion is considerable, we may 
perceive the enlargement of the side and the consequent deformity, the 
protrusion of the intercostal spaces, and perhaps the displacement, of the 
heart. 

Heyfelder has remarked that the child lies on the affected side, 
which is slightly cedematous, with its knees drawn up, in a crouching 
position. 

The child meantime becomes emaciated and pale ; the evening ex- 
acerbations are marked, followed by sweating during the night ; the 
appetite is lost, and at the end of some weeks or months the child sinks, 
quite worn out. 

It is quite possible, however, that the child may be saved, either by 
the absorption of the effusion, its removal by expectoration, or by a 
surgical operation. 

611. Complications. — These are not frequent ; Rilliet and Barthez 
have rarely seen any that could be fairly connected with the pleuritic 
inflammation. 

Convulsions sometimes usher in the attack, and occasionally there 
are some irregular cerebral symptoms connected with secondary pleu- 
risy. Rilliet and Barthez mention a case of meningitis which occurred 
in the progress of pleurisy, which itself was developed during the ex- 
istence of Bright's disease, but upon which of the two the meningitis 
depended it would be hard to say. 

Pneumonia may itself complicate primary pleuritis ; it is not very 
uncommon to find a thin layer of the pulmonary tissue inflamed beneath 
the serous membrane. 

512. Terminations. — Acute primary or secondary pleurisy may 
terminate, — 1. In resolution, with gradual subsidence of the inflamma- 
tion, and re-absorption of the effusion ; 2. In absorption of the fluid by 
the lungs, and its vicarious expectoration from those organs ; 3. In 
chronic pleurisy ; 4. Chronic pleurisy may terminate by re-absorption 
of the fluid ; 5. By its vicarious expectoration ; and 6. By a sponta- 
neous opening through the parietes of the chest, as in the case related 
by Dr. Battersby. 

513. Morbid Anatomy. — In the majority of cases, the pleura of the 
side affected is found smooth, pale, and semi-transparent ; in others, 
regularly and finely injected, or exhibiting patches of ecchymosis, espe- 



348 PLEURISY. — PLEURITIS. 

dally underneath the false membranes. In one case, Rilliet and Bar- 
thez found the pleura beneath the false membrane very vascular and 
softened, and in another case thickened. 

The sub-serous tissue is occasionally vascular. 

More or less fluid is found in the pleural sac ; sometimes simple or 
bloody serum, with flocculi of lymph ; sometimes the fluid is thick, 
yellow, and puriform, or of an intermediate character. 

The colorless, viscid, stringy fluid which we find occasionally is re- 
garded by Rilliet and Barthez as the result of inflammation. When 
there is a communication with the external air, the effusion may acquire 
a fetid odor. 

In most cases the effusion naturally occupies the most depending 
position, rising in the serous sac according to its amount ; in other 
cases, as in adults, it is contained in sacs formed either by old adhesions 
or recent false membranes. 

The pleura costalis and pleura pulmonalis are frequently covered 
with false membranes of varying size and thickness. Sometimes they 
are soft, and deposited in small patches; or they may be extensive, but 
very thin ; or several of their laminae may be super-imposed, forming a 
thick, solid layer. They are generally of a whitish-yellow color, but 
near the surface of the lung we find a tinge of red. Their free surface 
is irregular, unequal, occasionally nodulated, and sometimes connected 
with the opposite pseudo-membranous layer by bands. 

When the disease is of old standing, the fluid portion becomes ab- 
sorbed, the false membranes become dry and thin, forming adhesions, 
intimate or loose, between different portions of the opposite surfaces. 
Laennec has admirably described the change from false membranes to 
adhesions, and to his work I must refer the reader, as the process is 
essentially the same in adults and children. 

514. When the pleurisy is simple, the lung is pressed back either 
totally or partially to the vertebral column, its volume is diminished, 
and its substance is flaccid, smooth when cut, impenetrable to the finger, 
presenting that condition which has received the name of carnification. 
The extent of this change will, of course, correspond to the amount of 
the effusion. 

But in other cases the lower lobe of the lung is solid, heavy, and but 
slightly pressed back to the vertebral column. Its substance resembles 
the lung in a state of hepatization, but is firmer and less penetrable by 
the finger, and on pressure less sanguinolent fluid escapes. In such 
cases it is pretty certain that the hepatization preceded the effusion ; 
the lung, having become more solid, could not be compressed by the 
fluid beyond a certain point, but still it is more condensed by the pres- 
sure than it would otherwise have been. Rilliet and Barthez have at- 
tempted to point out the anatomical characters when the pneumonia*- 
succeeds to the effusion, but without much success. In the case they 
mention, the superior lobe was carnified and compressed, the inferior 
exhibited the different stages of pneumonia, was friable, sank in water, 
and on pressure no sanious fluid escaped. 

. 515. The same authors observe that simple pleurisy is more fre- 
quently unilateral than double, and rather more common on the right 



PLEURISY. — PLETJRITIS. 349 

side than the left ; and that when complicated with pneumonia it is still 
more frequently unilateral, but that the left side is more commonly af- 
fected. 

Taking all the cases, they found that pleurisy, complicated or simple, 
was more frequently unilateral than double, and more common on the 
left side than the right. 

Thus, in eighty-five cases, the disease affected the right lung only in 
thirty, the left in thirty-eight, and both in seventeen ; but of twenty- 
one cases of simple pleurisy, the right side alone was affected in eleven, 
the left in eight, and both sides in two cases. 

M. Baron has arrived at nearly the same conclusion. 

All M. Barrier's fourteen cases were unilateral except two; in twelve, 
it was seven times on the right, and five times on the left side. In six 
simple cases, it was five times on the right, and once on the left ; in six 
cases complicated with pneumonia, it was four times on the left, and 
twice on the right. 

Dr. Battersby rather agrees with Dr. Copland, that " pleurisy in 
every form, in children as well as in adults, is much more frequent in 
the left than in the right side. of the chest;" and this is in conformity 
with my own observations. 

The most frequent morbid lesion is the false membrane ; the next, 
the turbid serum; and least common, pus. The former is often the 
only lesion. The quantity of these products of inflammation varies, 
but it is seldom great. Rilliet and Barthez, Baron, and Barrier, state 
that the effusion is generally very inconsiderable, and in none of their 
cases was it sufficient to cause displacement of the heart. M. Hey- 
felder mentions cases from which six pints (chojnns) of pus were re- 
moved by operation. Dr. Battersby has related several cases in which 
the effusion was sufficient to dislocate the heart from its usual situation, 
and I have seen three or four. 

As to the adhesions, Rilliet and Barthez remark that in the great 
majority of cases they are parieto-pulmonary, next, costo-pulmonary, 
and lastly, interlobular. They met with costal false membranes alone 
in one case, interlobular in four, pulmonary in seventeen, parietal and 
pulmonary in fifty-six, parietal, pulmonary, and interlobular in one case. 

Of 137 cases in which adhesions existed, sixty were of the right pleura 
only, thirty-one of the left only, and forty-six of both. In ninety-three 
cases adhesions were the sole inflammatory product. 

516. Causes. — The age of the child appears to afford no exemption 
from the disease, but how far it enters fairly into the list of causes it is 
not so easy to say. It may certainly occur at any age, from a day old 
upwards. Billard and Berton believe that simple pleurisy is more com- 
mon among infants than is generally believed, but that it is much more 
so after five years; and M. Barrier's researches confirm this opinion. 

Rilliet and Barthez state that of twenty-one cases of simple pleurisy, 
eight occurred from one to five years, and thirteen from six to fifteen ; 
and of sixty-one cases complicated with pneumonia, forty-four were from 
one to five years old, and seventeen from six to fifteen. 

Dr. Stewart thinks that at the age of three years pleurisy is as com- 



350 PLEURISY. — PLEURITIS. 

mon as among adults ; M. Barrier, that it is rare before the sixth year. 
Dr. Battersby thinks that Dr. Stewart is nearest the truth, judging by 
his experience. 

Secondary pleuritis, or pleuritis combined with pulmonary diseases is 
more frequent among young children. In 3392 autopsies of children 
from one to two years old, M. Baron found pleurisy in 205, or six per 
cent. ; and in 181 autopsies from two to fifteen years old, the pleura 
presented evidences of inflammation in 158, or eighty-seven per cent. ; 
that pulmonary complications existed in two-thirds from one day to one 
month old ; in four-fifths, from one month to one year ; and in eight- 
ninths from one to fifteen years. M. Hache found the pleura inflamed 
in eighty-one out of 194 autopsies, and in none was it the simple dis- 
ease. M. Valleix mentions that of ninety-two cases under two and a 
half months, examined by M. Vernois, fourteen only showed signs of 
pleurisy, and of the whole number, one-sixth had been so affected. 
Mr. Crisp, in forty-one autopsies of children under two years old, dis- 
covered pleuritis in six ; in one, simple ; in five, combined with pneu- 
monia. M. Bairier observed no case of pleuritis independent of pneu- 
monia before the sixth year ; very few between the sixth and tenth ; 
but from the tenth to the fifteenth it was nearly as common as with 
adults. 

517. From the researches of Rilliet and Barthez, it would appear 
that simple pleurisy is more common among boys than girls ; in twenty- 
one cases, twenty were boys and one a girl. Secondary pleurisy is 
equally common in both, but what they call cachectic pleurisy prevails 
more among girls than boys. 

In eighty-two autopsies of boys, M. Hache found traces of pleurisy in 
forty-two, and only in forty out of 112 autopsies of girls. 

Children of a weak, scrofulous constitution seem to be more liable 
to the disease than those of a more healthy habit. 

M. Baron considers the disease more prevalent in winter ; Rilliet and 
Barthez in the month of April. 

Impure air, insufficient food, inadequate clothing, a prolonged sojourn 
in a hospital, lying too long on the back, seem to exercise as much in- 
fluence on the production of pleurisy as upon pneumonia. 

Exposure to cold is, perhaps, the principal exciting cause, but Rilliet 
and Barthez have seen it result from external violence. 

518. Simple pleurisy may occur secondarily in the course of rheu- 
matism, scarlatina, Bright's disease, &c. ; it is rare in the course of 
measles, although it may occur as secondary to the pneumonia which 
so often attacks children in measles. 

Secondary pleurisy more frequently complicates pneumonia than, per- 
haps, any other disease, either from contiguity of tissue, or by the 
rupture of a small abscess (480). 

It occurs, also, in tubercular disease of the lungs, in like manner, 
either by extension, or by the softening and evacuation of a tubercular 
mass. 

Bouchut mentions that he found pleuritis in twenty-three out of sixty- 
eight autopsies ; i. e., it was combined with acute pneumonia in nine,' 



PLEURISY. — PLEURITIS. 851 

with tubercular pneumonia in six, -with entero-colitis in five, and with 
other different diseases in three cases. 1 

519. Diagnosis. — The characteristic signs of simple pleurisy are the 
feeble respiration, gradually diminishing from below upwards, bronchial 
respiration, dulness on percussion, vocal resonance or egophony, and 
the absence of vibration. When the effusion is great, we may observe 
the prominence of the intercostal spaces, the deformity of the chest, 
and the displacement of the heart. 

In pleuro-pneumonia, as we have seen, the sounds increase in inten- 
sity, the dulness is absolute, the bronchial souffle almost cavernous, and 
the voice painfully resonant. 

No doubt the diagnosis in the commencement of the illness is often 
difficult, but yet I agree with Dr. West, who, after mentioning the diffi- 
culties, remarks : " But even then, and in spite of all the circumstances 
which have been enumerated as tending to mislead, you will seldom be 
wrong if you regard as an instance of pleurisy any case in which, 
symptoms like those of pneumonia having set in suddenly and severely, 
auscultation fails to detect the crepitus of pneumonia, and discovers 
only feebleness of the respiratory murmur on one side, with or without 
a more or less marked bronchial character in the breathing. 2 

There is also something peculiar in the aspect of the child, breathing 
shortly and quickly, holding the chest fixed, and moving cautiously as 
if fearing pain, which has led me to suspect pleurisy even before asking 
a question. 

520. Prognosis — The prognosis in pleurisy will vary according to 
the age of the patient and the circumstances of the case. Simple 
primary pleuritis, in children above five years of age, Rilliet and Bar- 
thez found to be a benign disease, and to terminate favorably when 
acute. Out of twenty-one cases to which they refer, none died. Hache, 
Constant, 3 \ . delocque, 4 Barrier, and Battersby, 5 concur in this 
opinion. J 

Of seventy-six cases treated at the Institution for Diseases of Chil- 
dren at Vienna, but two died. 

Mr. Crisp and Dr. Copland, however, give a different opinion ; the 
former considers it a disease of great danger, and the latter " that its 
effects are more to be dreaded, the younger the child which becomes the 
subject of it. 

The combination of pleurisy with pneumonia appears more serious 
than either disease existing alone, for of five such cases, related by 
Rilliet and Barthez, two died, and five out of six in M. Barrier's ex- 
perience. Chronic pleurisy Billiet and Barthez consider as still more 
unfavorable, contrary to the opinion expressed by M. Barrier, who 
found acute pleurisy more fatal than chronic ; and Dr. Battersby re- 
marks, there are many cases on record of recovery from uncomplicated 
empyema, after the occurrence of deformity of the chest, and even 
after the evacuation of the fluid by a natural or artificial opening. Dr. 

1 Mai. des Nouv. Nes, p. 345. 

2 Lectures on Diseases of Infancy and Childhood, p. 214. 

3 Gazette Med. de Paris, 1837, p. 265. 4 Lancette Fraucaise, 1837, p. 146. 
5 Dublin Journal, November, 1847, p. 385. 



352 PLEURISY. — PLEURITIS. 

Hughes performed paracentesis in four children between seven and nine 
years of age, and all recovered ;* and Heyfelder in three cases, between 
six and seven years old, with perfect success. 2 

521. Treatment. — The treatment of acute pleurisy does not differ 
very much from that of pneumonia. If the disease be primary, and 
the child strong, we must have recourse to liberal bloodletting, either 
from the arm, or by leeches to the side, or both. It may, very likely, 
be advisable to repeat this if the attack be severe, and the first attempt 
be only partially successful ; but in this we must be guided very much 
by the intensity of the disease, and the strength of constitution pos- 
sessed by the child. 

In secondary pleuritis it will probably be necessary likewise, but we 
must carefully estimate the importance and results of the primary dis- 
ease, as it is possible that this may preclude very active remedies for 
the secondary affection. After the proper treatment for acute pneu- 
monia, for instance, and the exhaustion and weakness produced by that 
affection, it is evident that, should pleuritis suddenly arise, our treat- 
ment of the latter must be very much modified. 

As a general rule, in chronic pleurisy bloodletting is rarely called 
for ; certainly, if we detect the commencement of the disease, it would 
be advisable, but this is seldom the case ; and at. the period when we 
are called to see the child, the mildness of the symptoms, the absence 
of fever, &c, rather indicate another line of treatment. 

522. If there be much fever, with a quick, firm pulse, and, above all, 
if pneumonia exist, we shall derive great benefit from the employment 
of tartar emetic for a few hours, given so as to produce slight nausea, 
but not vomiting. 

Dr. Condie speaks very highly of a combination of tartar emetic and 
nitre given in the following form : — , 

R. — Nitr. potassaa, gj. I 

Antim. tartar, gr. ij. 
Sacch. alb. ^ij. 
Aquae, §iv. 
A teaspoonful to be given every two or three hours, according to the age of the 
patient. 

523. Calomel, either alone or combined with James's powder, ipe- 
cacuanha, or tartar emetic, is a most valuable remedy. Small doses 
may be given two or three times a day from the commencement, and 
continued until the violence of the disease abates, unless diarrhoea 
should occur, or the gums become tender. If the state of the bowels 
forbid the continuance of the calomel, even though guarded by the 
pulv. cretse cum opio, or Dover's powder, we may substitute the hydr. 
cum creta;. I have before remarked that mercurial diarrhoea in children 
is nearly as good a sign of the constitution being under the influence of 
the mineral as ptyalism in the adult. 

The treatment by calomel, when it can be borne, is well suited to 
those cases of secondary pleuritis in which bleeding and tartar emetic 

1 Guy's Hospital Reports, Nos. 3 and 4, 1844. 

2 Arch. Gen. de Med., third Series, vol. v. p. 59. 



PLEURISY. — PLEURITIS. 353 

are counter-indicated, and in chronic' pleurisy, where they are unneces- 
sary and unsuited. 

524. I need hardly state that the bowels should be kept free through- 
out the attack. At the commencement, a brisk purgative will be found 
very beneficial; but, in repeating it, we must be careful not to occasion 
diarrhoea, if we wish to persist in the use of mercury. 

When diarrhoea exists, a little compound powder of chalk, with the 
powder of chalk and opium, may be given, or chalk mixture, with aro- 
matic confection and a few drops of laudanum. 

525. After the first acuteness of the disease has subsided, when the 
pulse is quieter, and the fever nearly gone, very great benefit will be 
derived from blisters, small ones and repeated, over the side affected. 
They are peculiarly applicable to secondary and chronic pleuritis, in 
connection with calomel and diuretics. 

In some cases, a sharp liniment will be sufficient, applied alternately 
to the back and front of the chest. 

526. The majority of writers are agreed upon the benefits to be 
derived from diuretics, given not in the very early stage of the dis- 
ease, but after the fever has somewhat subsided — and continued for 
some time. 

In secondary and chronic pleurisy, they are also of great value, not 
merely as a derivative, but as probably promoting the absorption and 
evacuation of the fluid effused into the chest. 

Squills, digitalis, and nitre, may be combined with the calomel, or 
formed into a mixture with mucilage, syrup, and water, or combined 
with an expectorant. Some mixture should be ordered to soothe the 
cough, and with this the diuretic may very well be combined. Dr. 
Eberle speaks highly of the tinctura sanguinariee canadensis. 

Warm baths at the beginning are very soothing, but at a more ad- 
vanced period of the disease they may exhaust the patient too much. 

As in bronchitis and pneumonia, I have found the patient derive 
benefit from a constant poultice of bread and water, or linseed meal, 
applied to the chest — over the dressing, if a blister have been applied; 
if otherwise, next to the skin. 

The diet must be low and simple until the acute stage be past, but 
then it may be gradually improved. The utmost care will be necessary 
during convalescence. 

527. I have already alluded to the operation of paracentesis in chronic 
pleurisy. The success of the operation seems to have varied in different 
hands. Dr. Henry Bennett, in his paper, 1 states that Boyer had per- 
formed the operation several times, but without success ; that Dupuy- 
tren had seen only two successful cases out of fifty ; Sir A. Cooper only 
one; Gendrin not one out of twenty on which he operated. Dr. Bennett 
himself has seen three unsuccessful cases. 

On the other hand, he has recorded six successful cases out of nine 
by Dr. Davies, and several by Dr. Hamilton Roe. Herpin succeeded 
in one case, and Heyfelder in three. Dr. Hughes mentions that within 

1 Lancet, December 30, 1843. 

23 



354 PLEURISY. — PLEURITIS. 

the last four or five years the operation must have been performed from 
twenty to thirty times in Guy's Hospital. 

528. As to the place and mode of operating, Mr. Cocks observes : 
"Auscultation and percussion are the best and surest means to detect 
the presence and the situation of the fluid, and on this and this alone 
we must place dependence. In the great majority of instances, the 
existence of the fluid will be most clearly indicated at the lateral and 
posterior part of the chest, in a position somewhat central between the 
upper and lower boundaries; and in every case which has come under 
my own hands, I have had occasion to tap below the angle of the 
scapula, between either the seventh and eighth or the eighth and ninth 
ribs, and at a point distant from one to three inches from the angles of 
the bones." " Our incapability of judging of the exact positions of the 
diaphragm, and the alterations which are liable to occur about the floor 
of the chest, from recent or old adhesions between that muscle and the 
base of the lungs, would lead me to deprecate the practice of making 
a low puncture. When we have the choice of two or three intercostal 
spaces, I would select the upper, or at any rate the middle one, as the 
least obnoxious to those casualties which may induce a failure in our 
object. Any advantage supposed to result from a depending opening 
can readily be obtained, as I shall presently show, by adapting the 
position of the patient to our purpose." 1 

Previous to the operation, Mr. Cocks always employs Dr. Babington's 
exploring needle, of which he speaks most highly, and deservedly. The 
instruments he employs for evacuating the fluid are, of course, the tro- 
car and canula, but of a smaller size than usual. He prefers them of 
one-twelfth of an inch in diameter, and about two inches in length, and 
of a circular rather than an oval shape. In some cases of oedema of the 
subcutaneous tissue, a longer instrument may be required. 

Mr. Cocks thus describes the operation itself, which inflicts very little 
pain : " It will be found most convenient to let the patient sit across the 
bed, so as to admit of his body being readily lowered and supported over 
the edge. The spot having been determined upon, it is advisable to make 
a small puncture in the skin, just at the upper edge of the rib, with a 
narrow-bladed lancet, through which opening the exploring needle, and 
subsequently the trocar, may be inserted. This preliminary step is 
not absolutely necessary ; but, as the skin is by far the most impene- 
trable and resisting of the tissues to be traversed, its previous division 
will render the introduction and withdrawal of the canula more easy, 
less forcible, and attended with a minor degree of pain and alarm to the 
patient. The exploring needle having been first introduced, and the 
presence of fluid ascertained, the trocar and canula may then be car- 
ried into the chest through the same track, giving the instrument a 
slight obliquity upwards, which will enable it to clear the edge of the 
rib. The depth to which the trocar must be passed will, of course, 
depend much on the thickness of the parietes, the presence of fat, 
muscle, or oedema, for which due allowance should be made ; and in 
most instances the penetration of the pleura will be appreciated by the 

1 Guy's Hospital Reports, 1844, No. 3, p. 67. 



PLEURISY. — PLEURITIS. 355 

sensation conveyed to the fingers of the operator, especially if the 
integument has been previously incised, so as to diminish materially the 
friction. 

" The remainder of the operation consists in getting rid of as much 
fluid as the strength and condition of the patient will bear, and care- 
fully avoiding the admission of air into the cavity. On withdrawing the 
trocar, the fluid will at first be found to flow in a steady and equable 
stream, slightly augmented in force at each expiration. After the lapse 
of a shorter or longer period, the flow will become checked at each in- 
spiration, and then the body of the patient should be gently lowered 
into a horizontal posture, and turned slightly over to the affected side, 
so as to bring the cavity directly over the opening ; and in this position 
he should be duly supported by assistants. The fluid will now recom- 
mence flowing in an uninterrupted stream ; and when it again begins 
to flag, a still further quantity may be obtained, if the state of the 
patient permit it, by directing an assistant to make steady and continu- 
ous pressure on the lower part of the chest, by grasping it on either side 
with the hand. This may be kept up for a period varying from a few 
seconds to a minute, until a continuous stream can no longer be ob- 
tained, when the canula should be immediately withdrawn. The greatest 
care should be taken to remove the tube, and thus close the opening, 
while the chest of the patient is yet in the grasp of the assistant ; but if 
he relax the pressure while the communication with the pleural cavity 
be still open, air will infallibly rush in. 

" During the whole process of evacuation, the unremitted attention of 
the operator should be directed to the stream of fluid, which he should 
never allow to become completely interrupted during the effort of inspi- 
ration. The admission of the slightest quantity of air is immediately 
indicated by a peculiar sucking noise, which cannot be mistaken, and 
which should be the signal for the withdrawal of the canula. The wound 
requires nothing but the application of a small dossil of lint and a strip 
of plaster, and the patient may then be laid down on the bed. If he 
complain of faintness during the operation, some wine or ammonia may 
be given." 1 

Dr. Hughes and Mr. Cocks have given the following resume of twenty- 
five cases in which the operation was performed : " Of these twenty-five 
cases in which paracentesis thoracis was once or several times per- 
formed, thirteen may be fairly stated to have recovered, so far as regards 
the effusion into the pleural cavity. Two may be justly mentioned as 
having at least partially recovered. One of these has, after seven years, 
a fistulous opening into the pleura; and the other has still some, though 
comparatively a very small quantity of fluid in the right pleura, but feels 
so much better as to be actually in search of employment in his profes- 
sion. Ten have ultimately died of other diseases, generally connected 
with that for which the operation was performed, but entirely inde- 
pendent of its performance. Of these ten cases ultimately fatal, six 
have died of phthisis ; one of gangrenous pulmonary abscess of the op- 
posite side ; one, after three months, of chronic pneumonia ; one rather 

1 Guy's Hospital Reports, 1844, No. 3, p. 74. 



356 PULMONARY PHTHISIS. 

suddenly, with hydrothorax in the other pleura ; and one, a case of 
pneumothorax with effusion (in which the operation was performed 
simply with the hope of affording temporary relief), of pneumonia and 
pericarditis." 1 



CHAPTER IX. 

PULMONARY PHTHISIS. 

1. This fearful malady, though less frequent than in adults, is by no 
means uncommon among the children of the poor, and such as are seen 
in foundling or children's hospitals, poor-houses, &c. ; in private practice, 
among more wealthy families, I do not think it is very common, except 
where it forms a part of a more general development of tubercles in 
scrofulous children. The characters, symptoms, course and termina- 
tion, very much resemble the same disease in the adult, so that it will 
be unnecessary for me to enter minutely into the different parts of its 
history. There exist, however, differences sufficiently marked to be 
worthy of notice, and which have a practical bearing upon our treat- 
ment. These deviations from the ordinary course of phthisis, I shall 
point out as we proceed, as briefly as I can. 

2. Experience has shown us that tubercular deposition is exceedingly 
common in infancy and childhood : thus M. Lombard found that one- 
eighth of the infants who died from one to two years old in the Hopital 
cles Enfans Malades, at Paris, were tuberculous ; two-sevenths of those 
from two to three years ; four-sevenths from three to four years ; and 
three-fourths of those who die from four to five years old. M. Papa- 
voine makes a very similar report. 

M. Guersent calculates that tubercles are found in two-thirds or five- 
sixths of all the children from one to fifteen years of age, whose bodies 
are examined after death. M. Barrier states that he found tubercles 
in thirty-eight per cent, of those who died from two to five years of age ; 
seventy-two per cent, in those from five to eight years ; 100 per cent, in 
those from eight to eleven years ; and seventy per cent, in those from 
eleven to fifteen years. In 130 autopsies, he found that tubercles ex- 
isted in seventy-five. 2 

Thus we see that the frequency of tubercular deposition is very great 
in the earlier years of life, and we further find that the organs most 
commonly affected are the lungs and bronchial glands ; but yet the lungs 
are not so invariably the seat of the morbid product in children as in 
the adult, for whereas M. Louis found in 125 adult cases, but one ex- 
ception to the law, that wherever tubercles were deposited in any organ, 
they were also found in the lungs, MM. Rilliet and Barthez met with 
forty-seven cases out of 312 tuberculous patients, in which the lungs 

1 Guy's Hospital Reports, 1844, No. 4, p. 366. 

2 Mai. de l'Enfance, vol. i. p. 329. 



PULMONARY PHTHISIS. 



357 



were entirely unaffected. This is the first deviation I have to bring 
before the reader. Dr. West has constructed a table, showing the com- 
parative frequency of the occurrence of tubercle in different organs in 
adults and children, which I shall take the liberty of extracting. 



Of 100 cases in which tubercle was deposited 
in some of the viscera, it was present 



Children from 






1 to 15 years. 


Adults from 20 


years and upwards. 


According to 


According to 


According to 


Rilliet and Barthez. 


Louis. 


Lombard. 


84 


100 


100 


79 


28 


9 


46 


33 


19 


42 


33 





40 


13 


6 


34 


2 


1 


27 








22 





1 


19 


10 





16 





2 


15 


2 


1 


11 


0.8 


2 


6 • 








3 









In the lungs 

" bronchial glands 

" mesenteric " 

" small intestines 

" spleen 

" pleura 

" peritoneum 

" liver 

" large intestines 

" membranes of the brain 

" kidneys . 

" brain 

" stomach . 

" heart and pericardium 

3. Symptoms. — The disease may set in during the course, or towards 
the termination of some other affection, especially if tubercular, and, of 
course, the symptoms will be modified more or less by the concurrent 
disease, or by the condition in which a preceding one may have left the 
patient. Or it may commence quite independently, and then the symp- 
toms resemble very much those in the adult, differing rather in degree 
than in kind. 1 

The child, at the commencement, seems unwell, loses its appetite, 
acquires a delicate semi-transparent look, complains of erratic pains in 
the chest, &c, even before alarm is excited by a cough. At first the 
cough is slight, dry, and more distressing by its frequency than its se- 
verity : as the disease advances, it becomes more troublesome, sometimes 
almost incessant, in other cases occurring in paroxysms. In a few cases, 
the cough is comparatively rare, attracting but little attention, but, 
nevertheless, it is present in almost every case. Rilliet and Barthez 
thus speak of this symptom: " The cough, once present, persists through 
the entire duration of the disease. It presents, it is true, great varia- 
tions in its characters and its intensity, but it is rare to find it sus- 
pended either completely or for a time. In one infant alone have we 
seen the cough commence after haemoptysis, cease after a time, and not 
reappear until after a recurrence of the accident." 2 

The respiratory movement is rarely natural, in general it is hurried, 
and sometimes extremely rapid, even up to 40, 60, or 80 in the minute, 
accompanied by an amount of dyspnoea, in some degree in proportion 
to the amount of tubercular deposit, whether the tubercles be softened 
or in a crude state ; or it may depend upon an accession of pneumonia 
or bronchitis, but if neither of these exist, it is stated to be a tolerably 
accurate measure of the extent of the disease. With some children we 



1 Barrier, Mai. de l'Enfance, vol. i. p. 649. 

2 Rilliet and Barthez, Mai. des Enfans, vol. iii. p. 277. 



358 PULMONARY PHTHISIS. 

see the entire chest dilate, in others respiration is mainly accomplished 
by the movements of the diaphragm, and in a third class it is entirely 
costal. 

In infants, there is no expectoration, and very rarely in children 
under six years of age ; whether it be that none is thrown off, or that it 
is swallowed, is not easy to decide ; from six to fifteen years, it is more 
abundant, and presents much the same character as in the adult, but it is 
not so easy to infer from them the presence of a cavity. Nor is hsemo- 
ptysis at all common; it is extremely rare at the beginning, and in the 
course of the disease it occasionally just tinges the sputa. Towards the 
end it may occur more abundantly, and may even terminate life some- 
what abruptly. MM. Rilliet and Barthez never saw it either at the 
commencement or in the course of phthisis, but in five cases the parents 
reported that it had occurred. Pain and uneasiness in the thorax is of 
uncertain occurrence ; many patients are too young to complain of it ; 
many have it not. When it does occur, it is sometimes behind the ster- 
num, sometimes between the shoulders or in either side. 

Night perspirations, although they do occur, are much less common 
than in adults. 

4. Thus affected, the child rapidly loses flesh and strength, and the 
color of the skin is altered, but the symptoms which especially charac- 
terize the hectic fever of consumption in adults, such as the quick hard 
pulse, heat of skin, hectic flush, perspirations and general irritability, 
are generally less intense. This M. Barrier is disposed to attribute to 
the less frequent occurrence of suppuration and cavities. 

Dr. West thus sums up the peculiarities of the symptoms as they 
occur in children: " 1. The frequent latency of the thoracic symptoms 
during its early stages. 2. The almost invariable absence of haemo- 
ptysis at the commencement of the disease, and its comparatively rare 
occurrence during its subsequent progress. 3. The partial or complete 
absence of expectoration. 4. The rarity of profuse general sweats, 
and the ill-marked character of the hectic symptoms. 5. The fre- 
quency with which death takes place from intercurrent bronchitis or 
pneumonia." 1 

5. It is evident that the symptoms already enumerated, although 
sufficient to excite our fears as to the disease, are by no means so cha- 
racteristic as those in the adult, and are inadequate alone to assure us 
of its true nature. But by adding to them the information afforded by 
percussion and auscultation, even though that be not always so certain 
as we should wish, we shall generally be able to remove all doubt. There 
are some peculiarities in the results of auscultation and percussion, which 
deserve our attention, and which have been succinctly pointed out by 
M. Barrier. " On account of the great resonance of the chest in chil- 
dren, it would require, in order to produce much dulness on percussion, 
that the tubercles should be both numerous and agglomerated ; there- 
fore, a very dull sound in children indicates a greater amount of tuber- 
cularization than an equally dull sound in adults. Moreover, in adults, 
the tubercles are generally concentrated at the top of the lung, produc- 

1 Diseases of Infancy and Childhood, p. 301. 



PULMONARY PHTHISIS. 359 

ing a circumscribed dulness rarely appreciable, whereas in children, 
this concentration at the summit being less frequent, and the dissemina- 
tion of the tubercles more general, the dulness is less circumscribed, 
less intense, and consequently less evident. But on the other hand, 
where dulness exists in adults, it corresponds generally to the advanced 
stage of phthisis, that is, to the presence of cavities ; but with children, 
phthisis remains most frequently in the first stage up to the time of death, 
and the dulness corresponds to the crude condition of the tubercles." 1 

The increase of sonoriety which we may occasionally observe in adults 
where cavities are formed, is necessarily less frequent in children be- 
cause cavities are so. In some cases where the tubercles are thinly 
scattered through the lungs, the results of auscultation may be almost 
negative ; but where they are collected in certain numbers, although both 
attention and an educated ear may be necessary, we shall generally be 
able to ascertain the true state of the case. 

One of the earliest auscultatory phenomena, in the stage of crude 
tubercles, is the prolonged expiratory murmur, first noticed I believe by 
the late Dr. Jackson, of Boston, U. S., and confirmed since by the re- 
searches of Andral, Fournet, &c. M. Hirtz, of Strasburg, has noticed 
a variation in the expiratory murmur in this stage, which he terms 
the bruit expiratoire rapeux ; the sound is at once rougher and clearer 
than the normal murmur. 

According to M. Fournet, 2 it is not only modified by a degree of 
roughness and dryness, but its intensity and duration are increased in 
comparison with the inspiratory murmur, which is diminished, although it 
also requires a degree of roughness, dryness, and difficulty. Occasional 
changes in the tone of the respiratory sounds may, however, modify or 
obscure the foregoing peculiarities. These changes consist at first of a 
clearer murmur than natural, which may gradually increase to what 
M. Fournet calls a timbre soufflant et bronchique, which may exist 
from the first to the last stage of tubercles. The same author has 
ascertained that all these changes commence with expiration, but that 
by degrees at a later period they involve inspiration also. 

Another sound, which has been termed a bruit de froissement, or 
craquement sec, has been mentioned as peculiar to the stage of 
crudity; but not only are these sounds obscure and observed with diffi- 
culty, but it would seem that their precise value and significance are not 
yet ascertained. 

MM. Billiet and Barthez regard the hardness (durete) of respiration, 
the prolongation of expiration with the sonoriety, as the most character- 
istic symptoms, but which are liable to be changed or masked by various 
circumstances. They attempt further to distinguish between miliary 
tubercles and the yellow or gray infiltration ; in the former, they state 
that the respiration is rough, expiration prolonged, and the sonoriety 
unaltered; in the two latter cases, by the feebleness or absence of the 
respiratory murmur, and the diminution of loss of sonoriety. 3 

There do not appear to be any special signs which correspond to the 

1 Mai. de l'Enfance, &c, vol. i. p. 651. 

2 Recherches Clin, sur 1' Auscultation et sur la Premiere Periode de la Phthisie. 

3 Mai. des Enfans, vol. iii. p. 247. 



360 PULMONARY PHTHISIS. 

softening of the tubercles until these are in process of elimination, and 
cavities commence to form. If the cavities are situated in the upper 
part of the lung, and are sufficiently large, we shall have the mucous 
rale, cavernous respiration, gurgling, perhaps pectoriloquy, and dulness, 
just as in the adult. Whilst the cavities are small, the value of the 
mucous rale "will depend upon its being limited to the situation of the 
tubercles, as it may also arise from bronchitic irritation, and when it is 
general, the probability would be that it does so. 

However, it must not be forgotten, as Rilliet and Barthez observe, 
that cavities do not always give rise to these peculiar signs, but rather 
to bronchial symptoms, as bronchial respiration, mucous rale, broncho- 
phony and dulness, and also that symptoms of cavities may be present 
without any cavity at all. 

The vocal resonance is changed in phthisis, during the earlier stage, 
especially in those parts where the tubercles are numerous or agglome- 
rated; the voice becomes more resonant, and occasionally we find bron- 
chophony ; at a later period, when cavities are formed, we may have 
pectoriloquy. In children as well as in adults, the vibration of the 
parietes of the thorax is diminished during the crude stage, and increased 
over large cavities, if any such form. 

These phenomena are generally present in children as well as in 
adults, nor are they much more difficult to ascertain generally ; the 
chief obstacle arises from the restlessness and unwillingness of the child 
to submit to examination, but with gentleness, patience, and a little 
coaxing, we may always attain our object. 

Externally, the two sides of the thorax may present different degrees 
of mobility, according as one side is more affected than the other. Oc- 
casionally, when cavities exist on one side, we may perceive a depres- 
sion of the subclavicular region, and this part is less dilated during in- 
spiration. According to M. Hirtz, the thorax becomes more cylindri- 
cal, i. e. the transverse diameter, which in the normal state is greater 
than the antero-posterior, gradually diminishes. Lastly, we may proba- 
bly perceive a difference of volume between the two sides of the chest ; 
but M. Barrier has given a case which shows that this is not always a 
proof of a greater amount of disease in the smaller. 

Dr. West thus enumerates the more important peculiarities in the 
phenomena observed by auscultation in the child : " 1, the smaller value 
of coarse respiration, prolonged expiration, and interrupted breathing, 
owing to their general diffusion over the chest, and to their occasional 
existence independent of phthisis ; 2, the apparent and to some extent 
the real exaggeration of the signs, both of the early and of far advanced 
disease of the lungs, in some cases of bronchial phthisis ; 3, the loss of 
that information which the phenomena of the voice furnish in the case of 
the adult ; 4, the small value of inequality of breathing in the two 
lungs ; 5, the difficulty of detecting minute variations in the sonoriety 
of the chest ; and 6, the existence of dulness in the interscapular region, 
together with moderate resonance of the upper parts of the chest, and 
tolerably good respiration there, which are characteristic of the pre- 
sence of enlarged bronchial glands." 1 

of Infancy and Childhood, p. 302. 



PULMONARY PHTHISIS. 361 

6. I have already mentioned that in many cases the symptoms are 
but slight, for some time after the commencement of phthisis ; but as 
the disease advances they assume a much more serious character, though 
not steadily progressive. We may observe great fluctuation ; some days 
the child seems better, with less cough and dyspnoea, and better appe- 
tite and spirits ; then an attack of bronchitis, or perhaps pneumonia, 
throws the child into a very distressing and alarming state; or the con- 
currence of bronchial phthisis presents a more aggravated condition than 
usual. As the disease advances, we find the cough generally more 
troublesome, the respiration more hurried and attended by wheezing, 
with little or no expectoration; if the child be young, it becomes rapidly 
emaciated and very feeble. Some degree of hectic may ensue, with par- 
tial night-sweats, but not at all as well marked as in adults. The mouth 
frequently becomes aphthous, and the stomach and bowels deranged ; 
and though diarrhoea is not uncommon, it does not alternate with the 
night-sweats as in the adult. "In a very large proportion of cases of 
phthisis, the functions of all the organs of the body become at length so 
much disturbed, and nutrition generally so much impaired, that the 
patient dies, because the whole machine is worn out. But though this 
is the case in many instances, yet it often happens, even where the powers 
had long seemed nearly exhausted, and the body wasted almost to a 
skeleton, that death is far from tranquil, but is preceded by hours of 
severe agony, for which it is not easy to account. In many cases, and 
especially in those where the disease runs a rapid course, the fatal termi- 
nation is due to an attack of intercurrent bronchitis or pneumonia, which 
is sometimes supposed to have been the patient's only disease, until a 
post-mortem examination reveals the tubercular degeneration of the 
lungs, to which the inflammatory affection was but secondary. Death 
from haemoptysis is rare, and still rarer is the perforation of the lung 
by the walls of the cavity giving way at some point, and thus producing 
pneumothorax. The abdominal symptoms sometimes mask the thoracic, 
and the patient dies of tubercular peritonitis, who, had life been pro- 
longed, would have sunk eventually under pulmonary phthisis. Many 
children in whom the signs of incipient phthisis have appeared, die of 
acute hydrocephalus, excited by the membranes of the brain having 
become the seat of tubercular deposit ; and some, in whom the disease 
has attained a more advanced stage, are suddenly carried off by head 
symptoms, the cause of which is explained by the discovery of large 
masses of tubercle in the cerebral substance. Convulsions, however, 
sometimes precede death for several hours, or head symptoms of greater 
or less intensity constitute the most striking feature in the patient's 
history for some days before death takes place, and yet an examination 
of the body throws no light upon the cause of their occurrence. Some- 
times, too, the symptoms that precede death are those of fever of a 
typhoid character, rather than of serious mischief in the chest." 1 

Such is the graphic picture of the termination of phthisis from the 
pen of no ordinary observer. From the beginning to the conclusion, 

1 Diseases of Infancy and Childhood, p. 309. 



862 PULMONARY PHTHISIS. 

the melancholy cases advance from bad to worse, with but rare intervals 
of comfort to the bystanders, fewer still of hope for the little patients. 

The entire duration of the disease varies a good deal. According to 
Rilliet and Barthez, it averages from three to seven months. M. Bar- 
rier states that the non-acute cases are not so prolonged as in the adult, 
and that the course is shorter in proportion as the child is younger. 
Dr. West mentions that he has known cases persist two, three, four, or 
nearly five years before terminating fatally. I should be inclined to 
think Rilliet and Barthez's estimate within the mark, at least for pa- 
tients in private practice. 

7. Modifications and Com/plications. — 1. Now and then we meet with 
unusually rapid cases of the disease; and, in such cases, we are liable 
to fall into an error of diagnosis, inasmuch as the symptoms present 
all the characters of an acute disease, and there is not time for the 
peculiar symptoms to manifest themselves. M. Barrier states that such 
are more common than in adult life. Dr. West has given the following 
case in illustration: "A remarkable instance of this came under my 
notice some years ago, in the case of a little boy, nine months old, who 
was fat and ruddy, and had always had perfectly good health until the 
10th of April. On that day, he was taken with symptoms which his 
mother supposed to be those of a bad cold. On account of this he 
was kept in the house, and various domestic remedies were employed, 
though without any improvement, and, on April 24, he came under my 
notice. There did not then appear to be any urgent symptom, though 
the child seemed much oppressed at the chest. The case appeared to 
be one of rather severe catarrh, occurring during the period of denti- 
tion. The gums were lanced, and a mixture containing the vinum ipe- 
cacuanhas was ordered, to which, finding the symptoms did not abate, 
small doses of antimonial were added on the 27th. On the 30th, I 
was informed that the child was much worse, that his dyspnoea was 
greatly increased, and that his hands and feet had been swollen for the 
last forty-eight hours. I found the little boy breathing fifty times in 
the minute, with great oppression at the chest, the face much flushed, 
the skin dry, the trunk hot, the limbs cool, and the hands and feet 
much swollen. Auscultation detected generally diffused small crepita- 
tion through both lungs, with indistinct bronchial breathing at the 
upper and back part of the left side. Three hours after this visit, the 
child died without a struggle, on being lifted out of bed for his mother 
to apply some leeches to his chest. On examining the body after 
death, a very thick layer of fat was found everywhere beneath the 
integuments. The lungs presented an extreme degree of tubercular 
degeneration, and many of the bronchial glands were enlarged by the 
morbid deposit to the size of a pigeon's egg. None of the tubercle in 
the lungs was softened ; but it existed both in the form of yellow mili- 
ary tubercle of tubercular infiltration and of masses of crude tubercle 
formed by the agglomeration of many separate deposits. The pulmo- 
nary substance in the intervals between the tubercular deposits was of 
a bright red color in the first stage of pneumonia, and in many parts 
bordering upon the second stage; and there was very considerable 



PULMONARY PHTHISIS. 363 

injection of the bronchial tubes. The various abdominal viscera con- 
tained tubercle, but it was not far advanced in the mesenteric glands." 1 
2. On the other hand, the disease may assume an unusually chronic 
form, and, instead of terminating in two or three months, may run on 
to a year, or even more. In such cases, however, we are not exposed 
to the same liability to error in our diagnosis. The patient, or the pa- 
rents, however, suffer more from the fluctuations of hopes and fears. 
I shall again trespass upon Dr. West for an illustration. " In March, 
1842, I saw a little girl, six years old, whose father had died of phthisis, 
and who had had a cough ever since she suffered from measles, two and 
a half years before. Her mother's anxiety had been excited by the 
increase of this cough, and by the child's losing flesh during the few 
weeks previous to her coming to me. Auscultation at this time dis- 
covered that air entered the lung in the left infra-clavicular region 
more scantily than in the right, and that the respiration was coarse and 
attended with much creaking at the upper part of both lungs. In May, 
the general symptoms were much improved, and the creaking sounds 
were no longer heard. For many months, the child continued to ap- 
pear tolerably well, though her cough never ceased entirely; but in the 
early part of the winter of 1844 her health completely failed. Exami- 
nation of the chest in the beginning of December elicited great defi- 
ciency of resonance at the upper part of the left lung, both in front 
and behind. Bronchial breathing, intermixed with large mucous rale, 
was heard in the left suprascapular region, and abundant moist sounds 
pervaded the lung posteriorly. In the left infra-clavicular and mam- 
mary regions, the respiration was very deficient, and accompanied with 
distant moist sounds. Extreme coarseness of the respiration was the 
only morbid sound heard at the upper part of the right lung, and the 
breathing on that side was puerile in other parts. In January, 1845, 
the child had slight haemoptysis, which recurred occasionally at intervals 
of a few weeks or months until her death, but was not profuse at any 
time. In September, 1845, resonance was slightly impaired under the 
right clavicle, and also in a greater degree posteriorly as far as the 
angle of the scapula. There was absolute dulness of the left side as far 
as the nipple in front and the angle of the scapula behind. There was 
no natural breathing in the left lung, but the respiration was bronchial, 
and accompanied with large mucous r&le as low as the nipple, the rale 
being smaller and the admission of air scanty below that point. About 
the left scapula, there were cavernous sounds and distinct gurgling, 
smaller moist sounds lower down. In the right lung, respiration was 
puerile in front, except quite at the upper part, where the breathing was 
coarse, and attended with mucous rale ; and posteriorly the characters 
were still more marked. It cannot be necessary to detail the results 
of the subsequent examination of the chest, which showed that disease 
advanced slowly in the right lung, though there was at no time proof of 
the existence of a cavity there. The child's condition fluctuated; some- 
times she seemed almost dying under an aggravation of all the symp- 
toms, and then again she rallied, and was able to walk about, and 

1 Diseases of Infancy and Childhood, p. 302. 



364 PULMONARY PHTHISIS. 

seemed tolerably comfortable. Life was prolonged until June, 1847, 
and she had seemed almost as well as usual until a very few days before 
her death.'' 1 This case, we see, lasted five years at least. I have 
under my care at this moment a little girl who has been similarly 
affected for two years, and as yet only the upper third of the left lung 
is involved, the remainder of that lung and the whole of the right being 
free. She is delicate, but quite able to go about, with but little cough, 
no night-sweats, little expectoration, no haemoptysis, some degree of 
emaciation, and a feeble appetite. Dr. West mentions another case, 
which has lasted still longer; and I doubt not that similar cases are 
occasionally met with by other medical men. 

8. Bronchitis. — I have already mentioned that the course of phthisis 
is often much modified by attacks of bronchitis, which are sometimes at- 
tributable to cold, and at other times occur without any assignable cause. 
They are marked by increase of fever, more rapid breathing, more dis- 
tressing cough, &c, and by the presence of bronchitic rales in one or 
both lungs. The extent varies ; sometimes it is very considerable, and 
accompanied with great exhaustion ; in other cases it is much slighter. 
By degrees the attack may subside under appropriate treatment, and 
the patient gradually recover a certain amount of health and comfort, 
but if not, it will, of course, hasten the progress of the primary disease, 
and shorten the patient's life. 

4. Pneumonia. — Another frequent complication of pulmonary phthisis 
in early life is pneumonia, which, according to Rilliet and Barthez, occurs 
more frequently before than after the tenth year. If it occur at an early 
stage before attention has been drawn to the tuberculous deposit, a su- 
perficial examination may easily lead to an erroneous diagnosis. Seve- 
ral causes for the attack have been enumerated by Rilliet and Barthez. 
"1. It may result from the local irritation of the pulmonary tubercle, 
and then it surrounds the latter, and we find the tissue of the lung hepa- 
tized and mixed with a variable quantity of miliary tubercles. It may 
either be lobar or lobular, but the latter form is more frequent. 2. The 
lung being very tuberculous, the pneumonia may be situated at the part 
most free, i. e. at the base, like the terminal pneumonia of adults ; it is 
always lobar, and can hardly be attributed to the irritation of the tu- 
bercles, but most likely to the susceptibility acquired by that part of the 
lung upon which its functions depend. 3. When the lungs are but 
slightly tubercular and other organs very much so, pneumonia may be 
developed which is not under the local influence of the tubercle. It is 
a secondary inflammation, analogous to that which complicates chronic 
catarrhs, and which exhibits the characters of cachectic phlegmasia. 
4. In cases where the tubercles are few, the pneumonia may be alto- 
gether independent of this cause, and is due to some other disease, as 
measles, hooping-cough, &c." 2 Both lungs may be attacked, but when 
one only is affected by .lobular pneumonia, it is more frequently the 
right, and when by lobar pneumonia, the left lung is more liable than 
the right. 

1 Diseases of Infancy and Childhood, p. 306. 

2 Mai; des Enfans, vol. iii. p. 243. 



PULMONARY PHTHISIS. 365 

I have already mentioned the difficulty of diagnosis, unless' sufficient 
care and attention be paid. It is of great consequence that we should 
ascertain the presence of tubercles, and not hastily assume that the case 
is one of ordinary pneumonia. " The existence of a considerable amount 
of tubercular deposit in the lungs may be imputed in those cases in 
which the degree of oppression of the chest has, from the very com- 
mencement of the illness, been altogether out of proportion to the se- 
verity of the catarrhal or bronchial symptoms with which the disease 
set in. A further evidence of its nature is afforded if the skin, though 
very dry, present a less considerable or less pungent heat than attends 
simple pneumonia, while the pulse from the very outset is less devel- 
oped. Suspicion would be strengthened if the frequency of respiration 
very greatly exceeded the amount of mischief disclosed by auscultation, 
and especially if the rapidity of the breathing, though so great that it 
would excite the most serious alarm if the case were one of pneumonia, 
should yet continue the same for days together, without marked deteri- 
oration in the patient's condition. Auscultation also would throw much 
light on the nature of the case, for the sounds detected in the chest 
would be the subcrepitant and mucous rales rather than the small crepi- 
tation of pneumonia, while, though the smaller sounds would be disco- 
vered at the lower part of the chest, the greatest dulness on percussion 
would generally be detected at the upper part, and bronchial breathing 
would very likely be perceived more or less distinctly in the same situa- 
tion." 1 

We must also take into account the constitution of the child and of 
his immediate relations, the presence of scrofulous disease in any of 
them will naturally confirm our suspicion of the existence of tubercles, 
and we must carefully observe the accordance or discordance of the 
signs and symptoms of each disease. 

The danger of this complication is very great, not merely as to the 
immediate shortening of the patient's life, but as destroying whatever 
little hope there may have been of a favorable issue, so that our prog- 
nosis should in all cases be very guarded. 

5. Bronchial Phthisis. — But pulmonary phthisis in children differs 
from the same disease in adults by the more frequent occurrence of tu- 
bercular deposition into the bronchial glands, or bronchial phthisis as it 
is termed. In the adult, this occurs about once in four cases of phthisis, 
but it is subsidiary to the pulmonary affection ; in children, it constitutes 
a very important disease, often more considerable and nearly as frequent 
as the deposition in the lungs. Dr. West states that tubercle existed 
in the bronchial glands in fifty-four out of fifty-five cases that came 
under his notice in which it was present in some organ or other ; in 
eleven of these cases it was in an incipient state; in twenty-five, all the 
glands were affected by it ; in twelve, the tubercle was both generally 
diffused and was more or less softened ; in two, the tubercle was in a 
firm, friable, cheesy state, and in four it had begun to undergo the 
cretaceous change. 2 

1 Diseases of Infancy and Childhood, p. 303. 

2 Ibid., p. 290. 



obb PULMONARY PHTHISIS. 

This form of disease generally occurs between the ages of two and 
six years, though it is by no means limited to that period. The symp- 
toms differ a good deal from those in the adult ; the attention may be 
first attracted by a severe attack of bronchitis, either after measles or 
independent of it. The cough and dyspnoea are the most prominent 
symptoms, the former is frequent and severe, recurring in paroxysms 
somewhat resembling those of hooping-cough, or those we observe in 
vesicular bronchitis. The respiration is hurried and oppressed with 
considerable wheezing, the veins of the neck are swollen and those of 
the surface of the thorax become dilated. " The great fluctuations which 
take place in the condition of the patient constitute one of the most 
striking characteristics of this form of phthisis. Attacks of bronchitis 
sometimes come on, during which the respiration becomes painfully ac- 
celerated and oppressed, and the paroxysmal cough is merged, for a time, 
in a constant hacking or suppressed attempts at coughing. These bron- 
chitic symptoms, which often seem to threaten life, and which sometimes 
actually destroy it, clear up by degrees, in the majority of cases, but 
leave the child with a severer cough and more hurried respiration than 
before, while it loses flesh rapidly, and not infrequently sweats a good 
deal about the head and upper part of the trunk. Accommodation of 
posture, too, in many instances, becomes necessary to the comfort of the 
little patient, who perhaps can breathe only when supported in its 
mother's lap, or when much propped up in bed. It is seldom when the 
disease has reached this degree of severity that there is entailed so large 
a measure of tubercular affection of the lungs and other viscera, as to 
render recovery quite hopeless, and the characteristic signs of bronchial 
phthisis become lost, by degrees, in those of ordinary consumption. 
Sometimes, however, a long pause takes place in the progress of the 
disease, even though thus far advanced; the cough, which had acquired 
fresh intensity, gradually abates ; the respiration is no longer habitually 
wheezing ; the patient can repose in any attitude ; the flesh lost is re- 
gained ; and were it not that the cough still continues, though less 
frequent and less severe, that the breathing is more hurried than natu- 
ral, and that auscultation contributes still further to undeceive us, we 
might fancy that all ground for anxiety was passing away, and that the 
child was on the high road towards recovery. In some cases, too, in 
which symptoms such as have been described are observed, recovery 
does eventually take place. It is seldom possible to say in any case by 
what means this recovery is brought about ; sometimes no doubt the 
tubercular matter makes its way into the air-tubes, and is got rid of by 
expectoration. Once I observed the disappearance of most well-marked 
general signs of consumption in the case of a girl eight years old, 
during the copious expectoration of a tenacious mucus in which were 
small quantities of a substance like broken down cheese, or grains of 
boiled rice, and which attenuated with an expectoration of thick puri- 
form matter more or less tinged with blood. In the case of this child, 
an attack of measles, while in her seventh year, had been succeeded by 
cough, the formation of abscesses in her neck, and a frequent puriform 
and sanguineous discharge from her nose. These abscesses had not been 
long healed, when her mother's alarm was excited by her expectorating 



PULMONAKY PHTHISIS. 367 

blood, mixed with the phlegm which she brought up when coughing. 
Though not much emaciated, the child looked unhealthy, her pulse was 
very feeble, and there were many small petechia on her extremities. 
The lungs, however, were tolerably free from disease ; for nothing more 
was heard during auscultation than a good deal of rhonchus mixed with 
some moist sounds, which were most evident at the upper part of the 
chest. Expectoration such as I have described continued for nearly 
three months, in the course of which the child by degrees lost her cough 
and acquired strength under the use of steel and other tonics. Two 
years afterwards no auscultatory signs of disease were perceptible, except 
a little creaking under both clavicles, and at the end of five years even 
this had disappeared." 1 

The signs and symptoms which accompany this affection are by no 
means always very characteristic; there may be but few signs present, or 
the cough, dyspnoea, &c, may be owing to the coincident deposition of 
tubercles in the lung, and if the latter be pretty well advanced, it will 
be quite impossible to distinguish between them. If, however, the 
patient be of a tuberculous cachexia, and has been placed in circum- 
stances to favor its development, and if the general symptoms, such as 
cough, dyspnoea, expectoration, &c, exist without any physical signs of 
disease of the bronchi, lungs, or pleura, we may have ground for sus- 
pecting the existence of bronchial phthisis. According to Mr. Barrier, 2 
the results of percussion are completely negative, when the disease is 
limited to the glands, and in general auscultation is little more satisfac- 
tory. Sometimes, however, the swollen gland compresses a bronchus, 
diminishing its calibre, and then the respiratory murmur will be enfee- 
bled in that part of the lung to which the tube is distributed. In such 
cases the clear sound on percussion, combined with the feebler respira- 
tion, cannot be attributed to tubercles of the lung, but would seem to 
justify our considering the case to be one of tubercular deposition in the 
bronchial glands. Both M. Becquerel and M. Barrier have verified, after 
death, a diagnosis founded upon this combination. Again, if the signs 
of a cavity appear in the neighborhood of the mediastinum, but nowhere 
else, we may presume without much hesitation, that they result from 
the suppuration of tubercular masses in the glands, and which may be 
voided through the larger bronchial tubes. 

The palpitations and anasarca which are sometimes produced by the 
tubercular matter in or near the mediastinum, pressing upon the larger 
vessels, are not of much value as to diagnosis, inasmuch as neither is 
uncommon in pulmonary phthisis. So that, upon the whole, it is evident 
that the distinction during life between bronchial and pulmonary phthisis 
is one of great difficulty, depending upon minute symptoms and close 
and accurate observation. At an advanced period, this is of no great 
consequence ; but as the progress of the former disease is much slower, 
it may be some comfort at an early period to know that the disease is 
one which, at least, admits of a considerable prolongation of life. But 
more than this, for it seems undoubted that bronchial phthisis is to a 

1 Dr. West, Diseases of Infancy and Childhood, p. 295. 

2 Mai. de l'Enfance, vol. i. p. 657. 



368 PULMONARY PHTHISIS. 

certain extent a more curable disease, or rather one in ■which recovery 
more frequently takes place ; and that, in various ways, either the 
tubercular matter may be absorbed, or it may be converted into creta- 
ceous substance, or the gland may suppurate, and emptying itself com- 
pletely into the bronchial tube, may heal ; and, if it be an isolated gland, 
the child may recover ; but such cases are rare. 

Death, however, rather than recovery, is the ordinary termination of 
the disease, either by suppuration of the tubercular masses which ex- 
hausts the patient, or while the tubercles are yet in a crude state; but 
more commonly by the participation of the lungs and other organs in 
the tubercular degeneration. The prognosis, therefore, is at best very 
doubtful, and in most cases very unfavorable. 

6. Emphysema and (Edema. — Rilliet and Barthez mention that 
both these secondary affections occasionally accompany tubercles of the 
lung ; but the former does not appear to hold any definite relation to 
them, whereas, the latter is either the direct result of the tubercles, or 
of the pressure exercised by them upon some of the pulmonary vessels. 

8. Morbid Anatomy.' — The pathology of pulmonary phthisis in chil- 
dren does not vary very much from the same disease in adults, and 
therefore I feel it the less necessary to enter fully into details. 

In the large majority of cases, both lungs are engaged ; out of seventy 
cases, M. Barrier found six only in which one lung alone was involved, 
and of these six cases, five were of the left lung, and one of the right. In 
sixty-four cases, both lungs were engaged, even though in a third of the 
cases, the disease was but slightly advanced. In twenty-two, the left 
lung was most affected ; in nine the right, and in thirty-three they were 
about equally so. 

As in adults, the apex of the lung is the part first and chiefly affected, 
the tubercles diminishing in number, and being less advanced as we 
descend. 

Unlike adults, in whom death seldom takes place until after the estab- 
lishment of suppuration and the formation of cavities (provided there 
are no complications), we find death occur in children, in whom almost 
all the tubercles are in a crude state, or at least before large or nu- 
merous cavities are formed. This many arise either from the greater 
rapidity with which extensive depositions of tubercle take place, causing 
death before there has been sufficient time for suppuration, or from the 
coincident occurrence of tubercles in other organs or glands. In eleven 
of thirty-three cases related by M. Barrier, there were either no cavities 
or extremely small ones. 

When tubercularization has gone to a certain length, the pleura is 
rarely found in a state of perfect health ; adhesions are very common, 
and tubercles are by no means rare. 

The bronchial glands, as I have already remarked, seem to be more 
frequently affected than the lungs themselves ; for M. Barrier states 
that of seventy-nine cases, sixty-nine had tubercles in the lung and 
bronchial glands, four in the bronchial glands only, and one in the lungs 
only. Dr. West mentions that tubercle existed in the bronchial glands 
in fifty-four out of fifty-five cases in which it was present in some organ 
or other; in eleven, it was in an incipient state; in twenty-five, all the 



PULMONARY PHTHISIS. 369 

glands were affected by it ; in twelve, the tubercle was both generally 
diffused and was more or less softened; in two, the tubercle was in a 
firm, friable cheesy state ; and in four, it had begun to undergo the 
cretaceous change. Any of the glands may be thus affected ; but the 
most important are those lodged in the mediastinum. 

As a general rule, the enlarged glands produce less inconvenience 
from compressing the neighboring parts than we might expect ; never- 
theless, we have sometimes to complain of such effects. The bronchial 
tubes may be compressed and flattened, or their coats may be thinned, 
eroded, or destroyed, the covering of the gland supplying their place 
and completing the wall of the tube. This, in the course of time, may 
give way, and the softened tubercular matter be poured direct into the 
bronchial tube. M. Guersent is said to have found the entire gland 
enucleated and passed into the tube. The pulmonary artery and veins 
may be compressed, and to this they are peculiarly exposed from their 
connection with the glands. The aorta may also be compressed, and 
its caliber diminished. M. Becquerel mentions a case of M. Durand's, 
of a girl whose trachea, large bronchi and aorta, were compressed by 
tubercular glands, which had thus apparently given rise to hypertrophy 
of the left ventricle. Compression of the vena cava thus effected may 
give rise to partial or general dropsy. The oesophagus is rarely altered 
in volume. 

As to the tubercles themselves, as in the adult, they may present 
themselves in the lungs in the form of miliary tubercles, or in masses, 
or diffused more generally through the substance of the organ. Whe- 
ther in the lungs or bronchial glands, the matter may be in either a 
crude or a softened state. In a crude state, the tubercles are either 
gray and semi-transparent or whitish or yellow, with a carious appear- 
ance, which generally succeeds the earliest stage. In the glands, the 
matter is sometimes deposited in such quantity that, instead of remain- 
ing isolated, several are joined, and form irregular masses of large size, 
in which, by dissection, we can trace the fibrous envelopes of each 
gland; but in the end these often disappear, and then the tumor will be 
simply surrounded by a general cyst. 

After a time, suppuration occurs, commencing generally in the centre 
of the tubercular mass, and proceeding to the centre until the whole is 
softened and evacuated by means of a communication with some of the 
bronchial tubes. A similar process takes place in the tuberculous 
glands; but, after the mass is softened, the attempt is made to evacuate 
the matter by perforating the cyst and reaching the nearest bronchial 
tube, through which the puriform matter is evacuated. An empty 
bronchial cyst may be mistaken for a true pulmonary cavity, if care be 
not taken; but it may be distinguished by its fibrous capsule, and also, 
according to Rilliet and Barthez, by the perforation into the bronchial 
tube being situated laterally. Occasionally, the suppuratory bronchial 
glands have perforated the oesophagus, and even the pulmonary artery, 
according to M. Berton. 

Tubercular matter, whether in the lungs or bronchial glands, may 
undergo calcareous transformation, though it is rare ; and this has been 
mentioned as one mode of cure. M. Becquerel has occasionally ob- 
24 



370 PULMONAEY PHTHISIS. 

served a steatomatous condition of the glands, which he regards as a 
transformation of tubercular matter. 

Dr. West enumerates four points in which tubercles in the lungs of 
children differ from those in the adult: 1. In the greater frequency 
with which gray granulations and crude miliary tubercles exist in the 
lungs independent of each other and of any other form of tubercular 
deposit ; 2. The greater frequency with which yellow infiltration of 
tubercle is observed in early life; 8. The greater rarity of cavities; 
and 4. The abundant deposit in the bronchial glands.* 

I do not presume to present this sketch to the reader as anything 
like a complete account of the pathological anatomy of tubercle, which 
will probably be already familiar to them from the perusal of the various 
valuable works we possess on pulmonary diseases, but rather as a notifi- 
cation of the peculiarities which it assumes in children, and of some 
points in which it differs from the disease in adults. Neither do I deem 
it at all advisable to enter into the causal origin of tubercles, how far 
they are independent of or how far they result from inflammation, &c, 
&.c. Such questions are doubtless of deep interest, and much light has 
been of late years thrown upon them, but they would be unsuitable in 
a work like the present ; and I must refer my readers to the various 
works on diseases of the chest, where they will find the subject treated 
with knowledge and acuteness far beyond mine. 

9. Causes. — There can be no doubt that a scrofulous constitution, 
whether inherited or acquired, is the most influential predisposing cause. 
Neither can we be surprised that close, dark, damp, unventilated dwell- 
ings, insufficient clothing, and scanty or improper food, should induce 
that condition of body which renders the liability to phthisis so fear- 
fully greater among the poorer population of towns and cities. 

The immediate cause of the attack is very often, if not generally, ex- 
posure to cold in some form or other; or the disease may succeed to 
some of the eruptive diseases, or to ordinary bronchitis or pneumonia 
in children in whom the predisposition exists. 

10. Diagnosis. — 1. In the early stage of the disease, the difficulty 
will be to distinguish between phthisis and bronchitis; but in the for- 
mer, we may have some degree of clulness at the upper portion of the 
lung, and a mixture of the crepitus of tubercles, neither of which will 
be found in bronchitis. The constitution of the child will also some- 
times throw light on the diagnosis. At the same time, we must not 
forget that both diseases may be present. At a later period, the pa- 
thognomonic characters are very different. 

2. From 'pneumonia. — A similar difficulty besets us here, for pneu- 
monia may complicate the case as resulting from tubercles, and to dis- 
tinguish this from simple pneumonia is by no means easy. We may 
derive some guidance from previous auscultation, if the lungs were then 
free from the secondary disease, and also from the duration of the pneu- 
monia ; or, if it be prolonged with alternations of increase and diminu- 
tion, we may suspect that it is tubercular. 

Again, tubercles are at an early stage confined to the upper part of 

1 Diseases of Infancy and Childhood, p. 288. 



PULMONARY PHTHISIS. 371 

the lung, simple pneumonia more frequently occupies the inferior por- 
tions, and the small crepitus of the latter disease is quite distinguishable 
from the tubercular rales ; and, lastly, the amount of fever is much 
greater in pneumonia than in uncomplicated phthisis. At a later pe- 
riod, when the tubercles are softened and perhaps cavities formed, the 
diagnosis from simple pneumonia is comparatively easy. 

3. I have already enumerated the distinctive points, slight as they 
are, between bronchial and pulmonary phthisis ; and I may add that in 
many cases such a diagnosis is not only very difficult, if not impossible, 
but somewhat unnecessary, as the diseases very seldom occur or con- 
tinue long separately. 

4. As to some other diseases from which it is desirable that phthisis 
should be distinguished, Dr. West observes that "it is important to bear 
in mind that strumous dyspepsia, as it has been called by many writers, 
is of more frequent occurrence in childhood than in adult age, and that 
its symptoms may be all that mark the advance of phthisis in the lungs 
until within a month or two of the patient's death. A definite com- 
mencement can always be assigned to the commencement of remittent 
fever ; and the great heat of skin, the very rapid pulse, the intense 
thirst, and the delirium at night which attend it, even in its less severe 
forms, are symptoms which, if borne in mind, would prevent our mis- 
taking for it those slighter and more vague ailments that are experienced 
during the first stage of phthisis. The referring the symptoms of in- 
cipient consumption to the presence of worms in the intestinal canal is 
a mistake even less excusable. The natural temperature of the skin and 
natural frequency of the respiration, the appetite at one time as raven- 
ous as it is deficient at another, the tongue either clean and moist or 
thickly coated, the condition of the bowels, which is generally one of 
constipation, and the marked relief which almost always follows the 
action of purgatives, are indicative of the presence of worms sufficiently 
characteristic to guard the attentive observer from error." 1 

11. Prognosis. — The prognosis is of course more or less unfavorable 
in all cases, absolutely so in most, as many more cases prove fatal than 
the contrary, few of those in whom the disease is fully established being 
rescued from an early death. Yet cases of restoration do occasionally 
occur, not frequently, but just in sufficient numbers to induce us to tax 
to the utmost our care and skill to give the patient the benefit of the 
slight chance in his favor. We should be a little guarded in attempt- 
ing to fix the duration of life, as we have seen that in some cases the 
disease seems almost indefinitely prolonged. 

12. Treatment. — I need say but little on this subject, as in principle 
the treatment of the disease in adults and in children is substantially the 
same, differing only in details. 

Perhaps the first and most important point to which our attention 
should be directed, is the air which the child breathes, and the atmo- 
sphere in which he lives. We must take care that this be pure, fresh, 
dry, and warm ; the rooms should be thoroughly ventilated and cleaned 
in the absence of the patient, and then when sufficiently warmed, the 

1 Diseases of Infancy and Childhood, p. 294. 



372 PULMONARY PHTHISIS. 

child may be brought back. During the winter months, I am strongly 
in favor of confining the child, not merely to the house, but to two or 
three rooms on the second or third floor if possible, so as to avoid expo- 
sure to draughts of cold air, and to sudden atmospheric changes and 
cold winds. If circumstances permit a change of climate, it is often of 
very great service. The South of England or Ireland, and still more 
the South of Europe, offer all possible advantages of this kind to the 
invalid. 

Even in summer, in this climate, undue exposure may do great mis- 
chief, and a prevalence of north or east winds, or damp weather, should 
be the signal for confinement to the house. When the wind is mild, the 
air dry and genial, then exercise in the open air, in the early stages of 
the disease, is beneficial, but at a more advanced stage, it should be very 
moderate, for obvious reasons. 

Inner garments of spun silk, web, or flannel, should be worn both 
winter and summer, as securing an equable warmth, and as a protection 
against a sudden chill, but they should never be worn in bed, as they 
then only increase the perspiration. 

Careful attention must be paid to the diet ; it should be at once simple 
yet nutritious, as very few patients recover who are not able to take a 
full share of nourishment. Milk in any form, farinaceous food, certain 
leguminous vegetables, jellies, broths, beef tea, and even solid animal 
food may be allowed, subject to the condition of the patient, the state 
of the digestive system, the stage of the disease, &c. Nay, in some cases 
even wine or beer may be advisable. On the other hand, if the stomach 
and bowels be weak or out of order, a careful selection must be made of 
those substances which experience has shown to be best tolerated by the 
stomach. 

As to the most suitable remedies, I shall not attempt to go through 
the list of those which have been proposed. It will be quite sufficient 
to point out a few of them which appear to deserve our confidence the 
most. In very few cases indeed is bloodletting admissible, and then 
only to the extent of a few leeches. These cases are generally those in 
which the disease is complicated by pneumonia, but even then our espe- 
cial object must be to exhaust the patient as little as possible. 

Counter-irritation is useful, and it may be practised by means of 
small blisters, the size of a watch glass, below the clavicle, or by the lini- 
ment, or by daily painting the same part with strong tincture of iodine. 
Much stress has been laid upon emetics, purgatives, chalybeates, &c, 
by different writers, and although I doubt not there are cases in which 
they may be beneficial, I fear their success has in no degree kept pace 
with the hopes which have been excited. The three remedies upon which 
most reliance seems to be placed are iron, iodine, and cod-liver oil. M. 
Barrier, however, speaks disparagingly of iodine, and even attributes to 
it an injurious influence upon the digestive functions. Iron has been 
supposed to counteract in some way the tuberculous cachexia, and Dr. 
Dupasquier, of Lyons, has derived more advantage from the iodide of 
iron than from any other preparation. My own experience is confirma- 
tory of his — and I have found a convenient form to be a grain of the 



PULMONARY PHTHISIS. 373 

salt to an ounce of syrup, of which a teaspoonful may be given three 
times a day to a child of three years old. 

At the present moment the most popular remedy is cod-liver oil, and 
whether from the iodine it contains, or from its nutritive qualities, it is 
not easy to determine, but we certainly have quite evidence enough to 
prove its great value in this disease. 

As a tonic, bark in some form is often useful, and for the relief of 
the cough, a mixture may be ordered containing ipecacuanha squills, 
and a little laudanum. Hydrocyanic acid has considerable control over 
the paroxysmal cough. 

Chalk mixture, with opium and some astringent, may be employed, if 
the bowels are relaxed. 

13. As to prophylactic measures, these consist mainly in incessant 
care and watchfulness — securing pure air, warmth, or even temperature, 
good diet, and guarding against cold, damp, improper food, &c. A very 
important point with infants who are likely to have inherited this pre- 
disposition, is to secure a healthy wet nurse from the country, and to 
let her suckle the child somewhat longer than the usual time, until the 
distress and irritation of teething be over. As the child advances, the 
opposite extremes of carelessness and over-care should be equally avoided, 
and when the intellect develops itself, we ought to be careful that the 
child be not stimulated to over-exertion or to too close application. 



SECTION III. 



DISEASES OF THE HEART. 



529. Before entering upon the consideration of the malformations 
or diseases of the heart, it appears to me that I shall be doing good 
service to my readers by extracting from the valuable work of Rilliet 
and Barthez their conclusions as to the normal state of the heart, and 
the results of auscultation and percussion in infants. They are based 
upon the examination of 193 cases, from fifteen months to fifteen years, 
and are as follows : — 

" 1. The circumference of the heart does not increase in proportion 
to the age ; it is nearly the same from fifteen months to five years and 
a half; from this time it increases irregularly up to puberty, but at the 
age of five years the limit is more marked when we measure the heart 
filled with coagula, as when empty its progression appears less irregu- 
larly increasing. 

"2. The distance from the base to the point anteriorly is nearly the 
half of the entire circumference at the base of the ventricles. 

" 8. The maximum thickness of the walls of the right ventricle varies 
little according to age ; it is generally two millimetres up to six years, 
after which it is ordinarily three or four. 

"4. The maximum thickness of the left ventricle is less than one 
centimetre up to six years old ; after which it is one centimetre, or a 
little more. 

" 5. The relative thickness of the two ventricles is generally, as 
pointed out by M. Guersent, as three to one or as four to one, rather 
more than less. 

"6. The maximum thickness of the septum is nearly the same as the 
left ventricle ; rather more than less. 

" 7. We will add a remark, the result of our notes, that the thickest 
part of the right ventricle is quite at the base, near the auricular open- 
ing ; of the left ventricle, one or two centimetres from the base ; and 
of the septum, from two to three centimetres. It follows that the more 
considarable the thickness the nearer it is to the middle of the height. 

" 8. The size of the right auriculo-ventricular orifice continues much 
the same up to the fifth year ; it scarcely increases up to the tenth ; but 
from this age its increase is marked. 

" 9. The left auriculo-ventricular opening, always smaller than the 
right, increases somewhat more regularly, and presents often the same 
dimensions as the distance from the base of the heart to its apex. 



DISEASES OF THE HEART. 375 

" 10. The aortic orifice shows but very slight increase between fifteen 
months and thirteen years. 

" 11. The pulmonary orifice, on the other hand, increases notably 
from the age of six or eight years, so that, whilst previously it is about 
equal to the orifice of the aorta, afterwards it is much more consid- 
erable." 1 

Eilliet and Barthez found no perceptible difference in their measure- 
ment between the two sexes. 

530. I shall now extract their account of the results of auscultation 
of the heart and percussion : — ■ 

" The precordial region presents ordinarily a diminished resonance, 
though rarely absolute dulness, in a portion of its extent between the 
nipple and the sternum, and is from four to seven centimetres vertically, 
and from four to eight transversely. This comparative dulness, there- 
fore, occupies a space, circular or elliptical, whose greater transverse 
diameter runs from the nipple to the sternum, and sometimes to the 
xyphoid cartilage, so that the nipple is central as to the height, and at 
the left extremity of this diameter. With children above six years, the 
nipple will sometimes be found above this centre. 

" The ear applied to this elliptical space perceives easily the two 
sounds of the heart ; the first is almost always duller (sourd) than the 
second. Around this central space the heart's action is weaker, accord- 
ing to the distance, although we can generally perceive the sounds, or 
at all events the second sound, all over the thorax anteriorly. 

" Ordinarily they are as audible, if not more so, beneath the right 
clavicle as the right nipple, owing, doubtless, to their being conveyed 
by the aorta superiorly ; but in a small number of cases the pulsations 
of the heart are transmitted more plainly to our ears in the region of 
the liver than superiorly. 

" In the normal state we have never heard the pulsations of the heart 
posteriorly. 

" In the great majority of cases, the sounds of the heart succeed 
each other with regularity, and the interval between them is always the 
same in the child ; some transient irregularities were merely exceptional 
and without value. Lastly, the radial pulse was always felt by the finger, 
just as the ear applied to the prsecordial region perceived the end of 
the first sound ; or, more correctly, the pulse corresponded to the com- 
mencement of the interval which separates the two sounds." 2 

1 Mai. des Enfans, vol. iii. Appendix, p. 662. 

2 Ibid., vol. iii. p. 265. 



376 MALFORMATIONS. 



CHAPTER I. 

MALFORMATIONS. — INTRA-UTERINE DISEASES. — CYANOSIS. 

531. It will be sufficient to enumerate very briefly the principal mal- 
formations to which the heart is subject, referring the reader for minute 
details to the elaborate works of Meckel, 1 Geoffroy St. Hilaire, 2 and to 
M. P. H. Berard's excellent article in the Diet, de Medecine, in thirty 
volumes. 

These malformations may be divided into — 

I. Anomalies as to Number. — There are examples of children born 
without hearts, but of course this is incompatible with extra-uterine life ; 
and as a general rule, such cases occur only in acephalous foetuses. 
Double hearts only occur in instances of diplogenesis. 

II. Anomalies of Position and Situation. — Instances have occurred 
of the apex of the heart being directed laterally to the right or left ; 
and it is said to have been placed vertically. 

When the heart is displaced, it may still remain on a level with the 
chest, as in those cases where, the parietes not being closed, it is pro- 
jected externally. M. Vaubonais relates a case in which " the heart 
was external, hung to the neck like a medal." Other cases are related 
by Buttner, Martinez, Haller, &c. 

Or the heart may be found elevated to the neighborhood of the head 
{ectopie cephalique of M. Breschet) as in the case related by MM. Bres- 
chet, Beclard, and Bonfils, where it was found in one between the bones 
of the jaw, and adhering to the tongue; in another, attached by its apex 
to the vault of the palate, and in a third, adhering, on the one hand, to 
the placenta, and on the other to the head. 

Or, lastly, the heart may be depressed into the abdominal cavity, in 
consequence either of an opening through the diaphragm, or from the 
absence of that muscle. In the former case, if the abdominal parietes 
are complete, the individual may live for years, as in the cases related 
by Ramel 3 and Deschamps. 4 When the abdominal parietes are incom- 
plete, life cannot be prolonged, even if the child be born alive, as in 
Mr. Wilson's cases. 5 

III. Malformations which do not permit the Mixture of Arterial and 
Venous Blood. — These cases are rare, and of little importance, in- 
cluding examples of bifurcation of the apex, multiplication of the cavi- 
ties, &c. 6 

1 Manuel d'Anatomie GeneYale, &c. 

2 Hist, des Anomalies de l'Organization. 

3 Journ. de Med. de Chir. et de Pharmacie, 1778, vol. xlix. p. 423. 

4 Journ. de Med., vol. xxvi. p. 275. 5 Philosophical Trans., 1789. 
6 Paget on the Congenital Malformations of the Heart. 



CYANOSIS. 377 

IV. Malformations which permit the Mixture of Arterial and Venous 
Blood. — These are, of course, of much greater importance, and some of 
them will involve a more lengthened consideration. According to M. 
Berard, the following are the principal instances : 1. When the heart 
forms but a single cavity, into which the vessels open at once. 1 2. 
When it consists of two cavities, an auricle and a ventricle, as in the 
cases of Wilson, 2 Standen, 3 Faure, Mayer, Ramsbotham, 4 Mauran, 5 and 
Breschet. 3. Where the foramen ovale remains open. I shall return 
to the consideration of this latter case and its consequences presently. 
4. M. Billard has included among the malformations of the heart, a 
narrowing of its orifices, which, however, may possibly have been the 
result of intra-uterine disease. He attributes it to a disproportionate 
growth in the heart and the orifices ; i. e. the latter do not increase as 
fast as the former, and thence result various disturbances of the circu- 
lation, and certain aesthetic affections. 6 

532. Let us add, here, that during intra-uterine life the serous mem- 
brane of the heart and pericardium may be the seat of inflammation. 
I examined a foetus recently in which I discovered intense pleuritis and 
pericarditis. Organic diseases, also, are occasionally observed. Bil- 
lard mentions a case of scirrhus ; Denis, hypersarcosis ; Cruveilhier, of 
aneurism of the aorta ; and Billard, of aneurism of the ductus arterio- 
sus, &c. 7 



CYANOSIS. 

533. Before entering upon the examination of this disease, which 
appears to be the consequence of a communication between the right 
and left sides of the heart, through the open foramen ovale, it is neces- 
sary to inquire as to the period when this foramen is ordinarily closed, 
and the mode by which it is effected, as we shall be then better able to 
judge of the results of its non-obliteration. I must here avail myself 
of the minute and interesting observations of M. Billard. 8 He states 
that "out of nineteen infants of a day old, the foramen ovale was com- 
pletely open in fourteen ; in two, partially closed ; and in two others, 
quite closed. In the same infants the ductus arteriosus was free and 
full of blood in thirteen ; partially obliterated in thirteen ; completely 
so in one. In the same infants the umbilical arteries were open near 
their insertion into the iliacs, but their calibre was diminished by a re- 
markable thickening of their parietes. 

"Infants of Two Days old. — Of twenty-two, there were fifteen of 
whom the foramen ovale was very free; three in whom it was almost 
obliterated; and in four, entirely closed. In thirteen, the ductus arte- 

1 Manuel d'Anat., vol. ii. p. 305. 2 Philos. Trans., 1798, p. 346. 

3 Ibid. 1805, p. 228. 

* London Medical and Physical Journal, June, 1829. 

5 Philadelphia Med. Journ., Aug., 1827. 

6 Mai. des Enfans, p. 605. 

7 Grsetzer, Krankheiten des Foetus, p. 160. 

8 Mai. des Enfans, p. 605. 



378 CYANOSIS. 

riosus was free; in six, partially obliterated; and in three, completely 
so. In all, the umbilical arteries were more or less closed, but the um- 
bilical vein pervious. 

" Infants of Three Days old. — Of twenty-two, there were fourteen in 
whom the foramen ovale was quite open; in five its obliteration had 
commenced; and in three it was completely closed. The ductus arte- 
riosus was free in fifteen ; its obliteration had commenced in five, and 
was complete in two only; but in these two the foramen was closed. 
The umbilical vessels were empty and even obliterated in all. 

"Infants of Four Days old. — Out of twenty-seven cases, in seventeen 
the foramen was open, and in six of them the opening was large and 
distended with blood; and in the remaining eleven, it was simply free; 
its obliteration was commenced in eight, and was complete in two. The 
ductus arteriosus was permeable in seventeen, partially closed in seven, 
and completely so in three. The umbilical arteries were obliterated near 
the umbilicus, but still dilatable near their iliac insertions. The umbili- 
cal vein and ductus venosus were empty and contracted. 

" Infants of Five Days old. — Out of twenty-nine cases, thirteen had 
the foramen ovale open, but not equally so ; it was nearly closed in ten, 
and effectively so in six others. The ductus arteriosus was open in fif- 
teen ; largely so in ten of them; partially obliterated in five; nearly 
completely in seven ; and quite so in seven others. The umbilical ves- 
sels closed in all. 

" Infants of Eight Days old. — Of twenty cases, the foramen ovale was 
free in five only ; it was incompletely closed in four ; and completely 
so in eleven. The ductus arteriosus was obliterated in all except three; 
the umbilical vessels in all. 

" We find from this last examination that the foetal openings are gene- 
rally obliterated in eight days, but that we may find them free at that 
age, or even at twelve or fifteen days, without the child suffering in con- 
sequence. 

" From the facts laid down before us, it follows that the foetal open- 
ings are not obliterated immediately after birth ; that the period when 
this takes place is very variable, but that in eight or ten days the fora- 
men ovale and the ductus arteriosus are generally closed. 

" From our examination we find that the umbilical arteries are first 
obliterated, then the umbilical veins, next the ductus arteriosus, and 
lastly, the foramen ovale. The persistence of those communications for 
some days after birth should not be regarded as a disease, seeing that 
it is very common, that it produces no ill effect, and that it is owing to 
the mode of obliteration." 

534. I shall next present to the reader M. Billard's account of the 
mode in which this obliteration is effected, merely premising that his 
observations have been confirmed by M. Berndt, of Vienna. If any 
apology be necessary for such long extracts, it will, I trust, be found in 
their importance, and in the fact that they are unique. 

" If we examine the disposition gradually assumed by the foramen 
ovale, from a short time after conception up to birth, we perceive that 
the form of this opening, the arrangement of the surrounding parts, and 
especially of the Eustachian valves, become such that the blood, which 



CYANOSIS. 379 

at first flowed freely from one auricle into the other, meets by degrees 
with more difficulty in doing so. Sabatier has strongly insisted upon 
this point. Thus, then, a modification in the organization of the heart 
has forced the blood to modify its course ; this fluid, inert by itself, is 
in immediate dependence upon the motor power which projects it, and 
directs it into the channels in which it ought to flow. If so, it follows 
that other changes will equally take place in those parts which the blood 
ought to forsake ; anatomical changes which, altering the form and modi- 
fying the action of the organs, will impress a new direction upon this 
fluid. Now, if we examine the umbilical arteries and the ductus arte- 
riosus, we shall find that in progress of obliteration their coats become 
thickened. This thickening of the umbilical arteries is especially re- 
markable at their insertion into the umbilicus ; at that spot they often 
present, after birth, a fusiform contraction, which diminishes the calibre 
of the arteries, and is able to resist the force of the column of blood 
projected by the iliac arteries." .... "Thus two causes force 
the blood, after birth, to abandon the course it took during intra-uterine 
life: 1. The establishment of respiration and the pulmonary circula- 
tion. 2. The modification of structure which the umbilical arteries un- 
dergo. Moreover, there is an experiment which proves that the con- 
tractility of the umbilical vessels can suspend the flow of blood through 
them. If we divide the cord, after birth, at some distance from the 
naval, the jet of blood is at first very strong, then it becomes slower, 
and afterwards stops altogether ; and if we cut off another portion, the 
same phenomenon occurs. It is owing, of course, to the contraction of 
the arteries upon the blood : and if this contractility exist near the um- 
bilicus and within the abdomen in a greater degree, on account of the 
greater amount of elastic tissue, one can understand the resistance they 
will be able to offer to the course of the blood in its more tranquil flow 
after birth. By degrees, as the infant grows older, the vascular tube is 
converted into a ligament. 

"That which happens with the umbilical arteries is observed also in 
the ductus arteriosus. In the embryo it is as yielding as other arteries, 
easily dilated by the column of blood which flows through it, without 
resistance, to the aorta. But at birth, and afterwards, its parietes be- 
come by degrees thicker by a sort of concentric hypertrophy which 
diminishes the calibre without apparently diminishing the size of the 
vessel, and in consequence of this resistance the blood which is ob- 
structed passes into the pulmonary arteries. At this period the duct 
presents the appearance of a pipe, whose walls are very thick and perfo- 
ration very moderate." . . . "If it be necessary that the foramen 
ovale and the ductus arteriosus should undergo organic changes which 
prepare and lead to their obliteration, one can easily perceive that the 
modifications may sometimes be effected prematurely, in others, very tar- 
dily ; so that on the one hand we find the foramen ovale closed soon after 
birth in some infants, or for a long time patent in others, and in most 
instances requiring some considerable but uncertain time for the com- 
pletion of these changes. Thus we may explain the irregularity ob- 
served in the time at which an independent circulation is established, 



380 CYANOSIS. 

without considering it as the cause or effect of disease of the heart or 
lungs. 

" However, the result will, no doubt, be an incomplete oxygenation 
of the blood, since all that the heart projects to the different parts of 
the body has not previously traversed the lungs, nor is in contact with 
the blood so renewed. 

"But after all, is it necessary that the blood of a new-born infant 
should be as highly oxygenated as that of an adult ? Is it not suitable 
that the recently completed and tender tissues of its organs should not 
receive blood too active — that the materials of nutrition should not be 
charged with principles too exciting, whose action upon the infantile 
organs might prove injurious to health, and even impede the progres- 
sive establishment of independent life ? I think so, and see no reason 
for rejecting the opinions which result from the examination of the cir- 
culating system in new-born infants. These conclusions are supported 
by another consideration, viz: that the lungs might be exposed to fatal 
congestions, if all the blood sent from the heart were conveyed to these 
organs by the pulmonary arteries. The ductus arteriosus, by allowing 
the superabundant blood to escape by it, relieves the respiratory organ, 
and permits a freer entrance of air into it than would take place if it 
were in a state of congestion, thus favoring the establishment of inde- 
pendent life by the persistence of those arrangements which were neces- 
sary during foetal life. Thus all is connected in a chain, the disposition 
of parts and the exercise of their functions ; everything progresses in 
order, and by transitions foreseen and provided for, so that no sudden 
and unexpected change disturbs the harmony of the vital phenomena. 

" If those openings persist much beyond the period already indicated, 
then, indeed, disease may be the result." 1 

After reading the valuable researches of M. Billard, we shall be 
better prepared to consider the disease in question, properly called 
" the blue disease," " morbus ceruleus," or cyanosis. 

535. Cyanosis consists in a blue, violet, or purple color of the surface 
of the body, and especially of those parts which are usually of a fresh 
or rose color, as the lips and other mucous surfaces, cheeks, &c. 2 

The color is very marked in the face, hands, feet, and genitals, and 
less deep in other parts of the body, presenting the aspect of extreme 
venous congestion. The color deepens during excitement or exertion, 
giving a very distressing appearance to the patient. 

The extraordinary color, however, would be of little consequence, 
were it not that it is attended with other disturbances of a more serious 
character. 

The action of the heart is very subject to derangement upon the 
slightest excitement or exertion ; the patient suffers from palpitation, 
fainting, &c, accompanied by bruit de soufflet, or the purring sound ; 
and there is, as we should expect, a marked disposition to serous effu- 
sion. 

The respiration is consequently and equally disturbed; hurried breath- 

1 Mai. des Enfans, p. 605. 

2 Copland's Dictionary, p. 199. "Blue Disease." 



CYANOSIS. 381 

ing, panting, dyspnoea, with a sense of suffocation, follow the least ex- 
ertion, or occur in paroxysms without any cause. In fact, as Dr. Copland 
remarks, "it may be said that the disorder is made up of a succession 
of paroxysms and remissions. In the paroxysms alone we observe 
those frequent faintings, that tumultuous palpitation of the heart, and 
suffocation, which endanger the life of the patients. No rule can be 
relied on as to the recurrence of these paroxysms ; in fact, if it be 
certain that they are brought on by over-exertion, fatigue, and violent 
mental agitation, it is equally certain that they occur without any as- 
signable cause, and are more frequent in winter than in summer. 

" The length of the paroxysm varies ; it sometimes last several hours, 
and generally abates gradually. 

" The termination of cyanosis is fatal to most patients, but some 
appear to recover entirely ; others live for many years." 1 

536. Pathology. — One circumstance is common to almost all these 
cases, and is discoverable in making a post-mortem examination ; I mean 
some mode of communication between the two sides of the heart. This 
may be effected in various ways : — 

1. The foramen ovale may remain open or may have been reopened ; 
and M. Gintrac 2 remarks that along with this patency there is gene- 
rally an obstacle to the passage of the blood from the right auricle into 
the right ventricle, or more frequently from the right ventricle into the 
pulmonary artery. This obstacle he found in twenty-seven out of fifty- 
three cases ; in twenty-six of the twenty-seven the impediment was in 
the pulmonary artery. 

2. The inter-ventricular septum may be perforated, as in some of M. 
Louis's cases. 3 

3. The ductus arteriosus may remain open, and, according to Louis, 
this is often coincident with the patency of the foramen ovale. 

4. The two auricles may open into the right ventricle, as in MM. 
Gintrac's and BreschetV cases, with perforation of the inter-ventricu- 
lar septum, or, as Haller 5 mentions, with one auricle for the two ven- 
tricles. In one of M. Gintrac's cases, the two auricles opened into the 
right ventricle, between which and the left ventricle there was a con- 
siderable opening. The aorta took its origin from the left ventricle. 

5. The pulmonary artery and the aorta may arise from the left ven- 
tricle, the right being almost obliterated, with a communication by means 
of the persistent foramen ovale, or perforation of the inter-ventricular 
septum. Hoist, of Christiana, and Gintrac, have related a case of this 
kind. 

6. The insertion of one or all the pulmonary veins into the vena cava 
superior. 

7. The presence of a second pulmonary artery arising from the right 
ventricle, and opening into the aorta ; or supplying the place of the 
aorta, which was obliterated after giving off the cephalic and brachial 
trunks. 

1 Diet, of Pract. Med., part. i. p. 200. 

2 Observations et Recherches sur la Cyanose, 1824. Paris. 
s Meuioires et Recherches Anatomico-pathologiques, p. 328. 

* Repertoire Gen. d Anatom., vol. ii. 5 De Monstris, vol. i. 



382 CYANOSIS. 

8. The transposition of arterial or venous trunks, as, for example, 
the implantation of the pulmonary artery upon the left ventricle, and 
the aorta upon the right, whilst the veins remain in their normal situa- 
tion ; or the opening of the veins into the left ventricle, the pulmonary 
veins, or even into the aorta. 

9. The pulmonary artery may be completely obliterated. 

10. The heart may consist of one auricle and one ventricle, as in the 
batrachise. 

11. There may be two superior vense cavse, one opening into each 
auricle. 

537. M. Louis has remarked the rarity of narrowing of the auriculo- 
ventricular, or the ventriculo-aortic orifices of the left side, he having 
met one case only, and that a slight one, in his twenty cases ; whereas, 
in the same cases, there were ten examples of narrowing of the orifices 
of the pulmonary artery, and one of occlusion of the auriculo-ventricular 
communication by ossification of the tricuspid valves, which were per- 
forated in many places. The narrowing of the pulmonary artery may 
be owing to the ossification of the sigmoid valves, united by their free 
edge, or to a species of diaphragm pierced in the centre, or by an ap- 
proximation of the parietes of the artery to the corresponding ventricle. 
M. Louis conceives the changes to have been either malformations or 
the result of intra-uterine disease. 

538. The condition of the heart itself is worth notice in these cases. 
M. Louis observes that, with one exception, his twenty cases were all 
examples of aneurism of one or more of the cavities of the heart. Dila- 
tation of the right auricle occurred in nineteen cases, with hypertrophy 
in six, and thinning of the walls in two. The right ventricle was dilated 
in ten cases, hypertrophied in eleven, and in five the hypertrophy and 
dilatation were coincident. But the left auricle was dilated only in 
three cases, hypertrophied in two, and the left ventricle dilated in four, 
and hypertrophied in three cases. 1 

M. Bouillaud states that the volume of the heart was augmented in 
eleven out of fifteen cases, and that in the majority of cases it was 
owing both to hypertrophy and dilatation of the right cavities. In ten 
cases the right auricle was dilated, in five of them it was hypertrophied 
also ; in five others it is not stated ; in five there was hypertrophy ; in 
five others it is not stated. In ten cases the right ventricle was hyper- 
trophied, and the hypertrophy was concentric. 2 

M. Bouillaud has also mentioned that in four of his cases the peri- 
cardium contained from three ounces to a pint of serum ; in two cases 
it was mixed with flocculi of albumen, and in one case there was false 
membrane and granulations on the surface of the right auricle. 

539. There is some difference of opinion as to whether the communi- 
cation between the two sides of the heart is congenital malformation, 
or the result of accident or disease. M. Louis, who has examined the 
question with his usual minute care, has arrived at the conclusion that 
it is an original malformation; but M. Bouillaud thinks that the per- 

1 Mem. et Recherches Anatomico-patkologiques, p. 334. 

2 Traite des Mai. du Coeur, p. 685. 



CYANOSIS. 883 

foration of the inter-auricular or inter-ventricular septum may have 
taken place from causes which have left no traces. M. Ferrus 1 also 
objects to attributing all the cases to original malformations, because of 
the sudden development of the consequences, which he thinks could not 
have been so long postponed if the cause had been longer in existence. 
M. Fabre, 2 however, very justly replied to this, that he has often dis- 
sected children in whom these malformations existed, but in whom the 
symptoms never occurred. He differs from M. Louis, in thinking the 
absence of any traces of disease about the opening a conclusive proof 
that it is a malformation ; and he concludes that in the majority of 
cases the communication is congenital, especially between the auricles, 
but that the perforation of the inter-ventricular septum is sometimes 
accidental. 

540. The effect of this intercommunication one would suppose to be 
the immediate mixture of red and black blood, or the reduction of the 
heart to the condition of a single one ; but such is not invariably nor 
necessarily the case. There will probably be no mixture of blood, 
although the foramen ovale be open, unless there be hypertrophy and 
dilatation of the right side of the heart, with narrowing of the auriculo- 
ventricular opening; and in like manner it will require a narrowing of 
the arterial orifices to occasion a mixture of blood where the ventricles 
communicate. And the coincidence of these changes is not unfrequent. 
M. Jules Cloquet and M. Bouillaud agree pretty nearly with this view 
of M. Louis, that when the foramen ovale remains open, the ductus 
arteriosus is pervious, the aorta springs from both ventricles jointly, and 
when to the communication between the right and left side of the heart 
there is superadded an obstacle to the free current of blood in the for- 
mer, a considerable quantity of black blood must, of necessity, mix with 
the red. 

The endocardial murmurs which are occasionally present are, no 
doubt, due to the narrowing of the auriculo-ventricular or arterial ori- 
fices, or to regurgitation. 

541. But are we to conclude that the discoloration of the skin is 
owing to the mixture of arterial and venous blood ? M. Louis says : 
" It is, then, impossible to maintain, either from reason or experience, 
that the blue color is due to a mixture of black and red blood, and the 
more that it appears that this mixture occurred in almost every case, 
whereas the blue color was by no means constant. Let us add, with 
M. Fouquier, that the skin of the foetus, in which black blood circu- 
lates, is not blue." He adds: " Morgagni seems to have given the true 
explanation in the case which we have quoted from him. To account 
for the livid color, he remarks that the constriction of the orifice of the 
pulmonary artery, in consequence of ossification, must have caused 
great embarrassment of the circulation; that the blood stagnated in the 
right ventricle, right auricle, and consequently in the entire venous 
system." 3 Corvisart seems to doubt whether the blue color is owing to 
this admixture of blood. 

1 Diet, de Med., en 30 vols., vol. ix. p. 536. 

2 Bibliotheque de He'd. Prat., vol. v. p. 379. 

3 Recherches sur plusieurs Mai., pp. 336, 344. 



384 CYANOSIS. 

M. Billard states that cyanosis is not the invariable result of the 
persistence of the foramen ovale, or the passage of the venous blood 
into the arterial system, inasmuch as there are many cases in which 
this took place without such results ; but it is probably due either to 
this mixture or to deficient oxygenation of the blood, whether there be 
intercommunication, or whether the blood be incompletely changed in 
the lungs. M. Bouillaud expresses a similar opinion ; he regards cya- 
nosis as essentially due to a deficient oxygenation of the blood, whether 
the structure of the heart be perfect or not. 

The late Dr. Stille thought that no one lesion is to be considered as 
the anatomical character of cyanosis, but that it depends simply upon 
any cause, which, acting at the centre of the circulation, will produce a 
stasis of blood in the capillary system. 

Dr. Chas. D. Meigs regards cyanosis as asphyxia resulting from black 
blood in the brain, and not in the lungs; that the danger consists in the 
cerebral condition, and is to be removed by supplying the brain with 
oxygenated blood ; and, lastly, that the blue color is caused by the 
presence of black blood in the capillaries. 

The prolongation of life, according to M. Louis, bears no relation to 
the symptoms, nor to the supposed condition of the blood. The sub- 
jects of this disease may die in infancy, or may live to twenty, thirty, 
or fifty years of age. Neither is it incompatible with the due develop- 
ment of the intellectual faculties. 

542. Treatment. — As far as the disease depends upon organic imper- 
fection of the heart, so far it is evidently beyond the reach of our 
means of cure, although some alleviation may be afforded. We are 
not, however, to conclude that no reparation is possible, because we 
cannot effect it or discover how it is to be done. It is for us to assist 
the efforts of nature by securing the conditions most favorable to the 
present comfort and permanent benefit of our patient, such as bodily 
and mental repose, a pure, mild air, with careful attention to the sto- 
mach and bowels. 

M. Bouillaud recommends bloodletting during a paroxysm ; but Dr. 
Copland objects to this, as seldom relieving the paroxysms, and naturally 
increasing the disease. Counter-irritation to the chest, by dry cupping, 
mustard poultices, or blisters, may be of use. 

"I have derived," says Dr. Copland, "more advantage from stimu- 
lating pediluvia, frictions of the surface of the body and lower extre- 
mities, and the administration of gentle antispasmodics and stimulants. 
In one or two instances, I conceived that some advantage was derived 
from the preparations of iron, combined with the fixed alkaline car- 
bonates." 1 

Dr. C. D. Meigs's remedy as applied to infants at birth is very inge- 
nious. It occurred to him when in attendance upon a case. He thought, 
"If I bring the septum auricularum into an horizontal attitude, will not 
the blood in the left auricle press the valve of Botalli down upon the fora- 
men ovale, and thus save the child by compelling all the blood of the 
right auricle to pass by the iter ad ventriculum, and so to the lungs to 

1 Dictionary of Practical Medicine, part i. p. 201. 



PERICARDITIS. 385 

be aerated." 1 He accordingly placed the infant on its right side, the 
head and trunk inclined upwards about twenty or thirty degrees. Im- 
mediate relief was afforded; the child became quiet, breathed more 
naturally, and acquired shortly its natural color. Dr. Meigs states that 
he has thus repeatedly succeeded, and he quotes abundant testimony 
from his pupils to the same effect. 



CHAPTER II. 

INFLAMMATION OF THE PERICARDIUM. — PERICARDITIS. 

543. The only diseases of the heart of which I shall treat are inflam- 
mation of the investing and lining membrane, i. e., pericarditis and 
endocarditis, with a slight notice of their consequences. It is only 
since Laennec's brilliant discovery of the power of auscultation in de- 
tecting disease that we have had the means of acquiring information 
about these affections during life; but it is within a few years that our 
knowledge has acquired any degree of certainty. 

Previously, dissection had proved the occurrence of pericarditis in 
childhood, but such was its obscurity that it was generally passed over 
in works on diseases of children. Cases were published by Lieutaud, 
Schmidel, and Koppel. Krukenbergius 2 and Roux 3 detailed some which 
occurred during the course of scarlatina and measles, and Vieussieux, 
Davis, "and Wells, others which occurred during an attack of rheuma- 
tism. Puchelt collected most of the scattered cases, and published them 
in a memoir, with others he had observed himself ; but it was not until 
the labors of Stokes, Watson, and others, in Great Britain, and Bouil- 
laud, in France, that much light was thrown upon the disease, either in 
the adult or in children. Since then, it has been noticed by Billard, 
Rilliet and Barthez, Condie, West, &c, in children. 

544. Pericarditis, or inflammation of the serous membrane which 
lines the pericardium and covers the heart, is not a very common dis- 
ease of infancy and childhood ; but neither, on the other hand, is it 
extremely rare. In 700 autopsies made by Billard at the Hopital des 
Enfans Trouv&s, he found seven presenting evidences of pericarditis. 4 
Dr. West states, "In six out of 170 cases in which the state of the tho- 
racic viscera was carefully examined, he discovered evidences of inflam- 
mation of the pericardium or endocardium, or both." 5 

At a meeting of the South London Medical Society, in the debate on 
Mr. Crisp's paper on pleurisy in children, Dr. Todd stated it to be his 

1 Obstetrics, p. 641. 

2 Jahrbucker d. Ambulatorischen Klinik, vol. i. Halle. 

3 De Carditide exsudativa, p. 47. 4 Mai. des Enfans, p. 623. 
5 Lectures on Diseases of Infancy and Childhood, p. 317. 

25 



386 PERICARDITIS. 

opinion that the pericardium was oftener the seat of inflammation in 
young than in older persons, and by no means rarely so in infants. 1 

The disease may either be acute or chronic; of the latter, however, 
we know but very little, as it is the acute symptoms which generally 
attract attention. 

Again, it may be either primary or secondary, the former being ex- 
ceedingly rare. It is seldom met with in adults, according to Dr. Latham, 
and still more rarely in children. Our chief knowledge of the disease 
in the living subject is drawn from those cases in which it occurs in the 
course of other diseases, such as rheumatism, the eruptive fevers, pleu- 
risy, &c. 

545. Dr. West has given a case of idiopathic or primary pericarditis, 
which I may be excused for copying, on account of its rarity and inte- 
rest. The subject of it was "a healthy boy, eleven years old, who, on 
May 8, 1843, complained of feeling cold, and began to cough. The 
chilliness was succeeded by fever, and he continued gradually getting 
worse till the 13th, when I visited him for the first time. He had had 
no other medicine than a purgative powder. On May 13th, I found 
him lying in bed, his face dusky and rather anxious, his eyes heavy, 
and his respiration slightly accelerated ; coughing frequently, but with- 
out expectoration; skin burning hot, and pulse frequent and hard. He 
made no complaint, except of slight uneasiness about the left breast. 
On examining the chest, there was found to be very extended dulness 
over the heart, with slight tenderness on pressure. A very loud and 
prolonged rasping sound was heard in the place of the first sound, loud- 
est a little below the nipple, though very audible over the whole left 
side of the chest, and also distinguishable, though less clearly, for a 
considerable distance to the right of the sternum. The second sound 
was heard clearly just over the aortic valves, but was not distinct else- 
where, being obscured by the loudness of the bruit. Respiration was 
good in both lungs. 

" The child was cupped to ovj. between the left scapula and the spine, 
and gr. i. of calomel, with the same quantity of Dover's powder, was 
given every four hours. 

"On the following day", it was found that the sense of discomfort in 
the chest had been relieved by the cupping, and that the child had slept 
well in the night. He looked less anxious, though his eyes were still 
heavy and suffused, and his skin was less hot and less dusky. His pulse 
was 114, thrilling, but not full. There was now slight prominence of 
the cardiac region, and the heart's sounds were obscurer and more dis- 
tant than on the previous day. The bruit was now manifestly a friction 
sound, louder at the base than at the apex of the heart, and altogether 
obscuring the first sound, while the second sound could be heard over 
the aortic valves. Six more leeches were applied over the heart, and 
the hemorrhage from their bites was so profuse as to occasion some 
faintness. Mercurial inunction was now superadded to the treatment 
previously employed, and the child's condition continued through the 
15th to be much the same as it had been on the previous day. On May 

1 Medical Gazette, Dec. 25, 1846. 



PERICARDITIS. 387 

16th, there was some improvement in the general symptoms, and the 
pulse was softer. The friction sound was now no longer audible, but a 
loud rasping sound was heard in the place of the first sound. The 
second sound was now distinguishable at the apex of the heart, as well 
as over the aortic valves, and its character was quite natural. On the 
17th, the mouth was slightly sore, and the dose of the remedies dimi- 
nished. On the 22d, the soreness of the mouth was considerable, and 
all active treatment was discontinued on that day. The child gradually 
regained his strength, but the bruit accompanying the first sound con- 
tinued, and was heard a month afterwards, with no other change than 
being rather softer and more prolonged. Four years afterwards, I saw 
him again. He had continued well in the interval, and had never suf- 
fered from palpitation of the heart, nor from any other ailment referable 
to the chest; but his pulse was small, jerking, and not always equal in 
force, and the natural character of the first sound was altogether lost in 
a loud, prolonged bruit." 1 

This case is of great value, both on account of the accurate picture 
of the disease it presents, and from its simple character and history. 

The characteristics of the heart disease are pretty much the same, 
whether as a primary or secondary affection. 

546. Symptoms. — The symptoms of pericarditis are not very striking, 
and in infants are necessarily more obscure than in adults, because a 
very young child's expression of pain or uneasiness is always more or 
less confused. When it occurs in the course of other diseases, also, our 
attention maybe so fixed upon the important primary affection, that we 
may overlook the slight but essential changes which mark the incursion 
of a new disease. No better illustration could be given of the value of 
a rule which I have adopted for many years, and which I strongly 
recommend to my readers, viz: when first called to see a child, no 
matter for what disease, to examine every organ of the body, and to 
repeat this examination at intervals of a few days. By so doing we 
shall often ascertain the commencement of secondary affections before 
they give rise to any complaint of distress. 

Probably the earliest symptom we shall notice of the disease in 
question will be uneasiness or pain in the left side of the chest, in the 
precordial region, near the left mamma ; this pain will be expressed if 
the child be old enough, or if not we may detect it by the position in 
bed, the restrained inspiration, the suffering on percussion, or on being 
moved. In Constant's, Mayne's, and Billard's cases it was pretty 
severe; in Puchelt's, not very acute; and in Rilliet and Barthez's cases 
it occurred but rarely, and was not severe. 

It will be less marked, or at least less pathognomonic, when the pri- 
mary disease is pleurisy or pneumonia; but in fever or rheumatism any 
uneasiness in the left side of the chest ought at once to excite our sus- 
picions, and direct our most careful attention to the state of the heart. 

The respiration, too, has a peculiar character in general; it is not 
the dyspnoea of obstructed lungs, nor is it any form of cerebral respi- 
ration, but it is high, rapid, yet restrained and suffocating, with quick 

1 Lectures on Diseases of Infancy and Childhood, p. 307. 



388 PERICARDITIS. 

movement of the alee nasi, and a difficulty of speaking sentences, as 
though the interruption to the short, quick inspirations, necessary in 
speaking, were intolerable. 

This again will be masked if there exist any pulmonary disease, but 
in other cases it is very striking. 

If there be no disease of the lungs, there will be but little cough, if 
any, but when these organs are affected, we may be at a loss to separate 
and distinguish the symptoms peculiar to each disease. 

Palpitation, owing to irregular action of the heart, is seldom trouble- 
some, but the violent action of the organ is sometimes felt in a distress- 
ing manner. 

The pulse is very quick, strong, and wiry. The face has an anxious, 
drawn, distressed, almost frightened expression; in two cases Billard 
observed spasmodic movements of the limbs ; the child cries often, 
as if suffering extremely, and generally objects to lying flat down in 
bed. 

547. But all these signs would only excite our suspicions that some 
grave lesion existed ; they afford us no precise information as to its 
nature. This we can only obtain by a careful estimate of the physical 
signs ; but then it is satisfactory to know that these are amply suf- 
ficient. 

The natural sounds of the heart are dull or muffled, though generally 
distinguishable. This obscurity increases for some days, occasionally 
varying ; its maximum is just beneath the mamma, and it appears to 
depend either upon the effusion of fluid, or upon the exocardial mur- 
murs occasioned by the disease. In eight out of nine cases related by 
llilliet and Barthez, both sounds were obscure ; in one, one of the 
sounds only. Although the sounds are muffled, they are not weakened, 
but, on the contrary, may even be louder than natural, with increased 
impulse. The exocardial murmurs are thus described by Dr. Williams: 
"Those of pericarditis are various sounds of superficial friction, which 
are quite characteristic. At first this sound is soft and rustling, like 
the rubbing together of two pieces of paper or silk stuff; and it may 
accompany only part of the natural sounds, from which, however, it is 
obviously distinct, in being much more superficial. It is generally 
heard first about the middle of the sternum, or to the left of it, corre- 
sponding with the base of the heart or the attachment of the auricles ; 
it afterwards increases in loudness and duration, being heard beyond 
the immediate region of the heart, and accompanying not only the 
periods of the natural sounds, which it disguises, but also the interval 
between them. It thus gets a sort of continuous jogging rhythm, cor- 
responding with the movements of the heart, which is like that of the 
saddle when one rides on horseback ; and when, as it generally hap- 
pens, the friction sound becomes harder, and more like the creaking of 
leather, its resemblance to the noise of a new saddle is quite ridicu- 
lous. In some cases the noise is crackling, like that of crumpled dried 
membrane or parchment." " These friction sounds are certainly caused 
by the rubbing of lymph on the pericardium proper, and on its sac." 1 

1 Diseases of the Lungs, p. 235. 



PERICARDITIS. 389 

When effusion takes place, so as to separate the opposing surfaces of 
the pericardium, these friction sounds are, of course, impossible, so that 
they are heard chiefly during the early stage of the disease, and again 
when the process of absorption has removed the principal portion of 
the fluid, except in those cases where there is little effusion. The 
sounds are generally audible in whatever position the child may be 
placed, but in two cases Rilliet and Barthez found them more evident 
in a sitting posture. 

Along with these exocardial murmurs we occasionally hear a bruit 
de soufflet accompanying the first or second sound of the heart, but this 
does not result from pericarditis, but from coincident endocarditis, of 
which I shall speak presently. 

If the effusion be small, the respiratory murmur will be audible in 
the pericardial region, but if large, the lungs will be, to a certain ex- 
tent, displaced. 

Dulness on percussion is another sign of considerable value ; it is 
almost always more absolute than usual in the prsecordial region, but 
its extent will depend upon the amount of effusion. When this is con- 
siderable, the dulness will be proportionally extensive, and not only so, 
but the prsecordial region acquires a degree of prominence ; the inter- 
costal spaces are protruded, and subside as the effusion is absorbed. 

Thus the physical signs of pericarditis are muffled sounds and increased 
force of the heart, exocardial murmurs, dulness on percussion, and ful- 
ness or prominence of the praecordial region. 

548. I have already mentioned that the pulse is quick, the skin is hot 
and feverish, the tongue loaded or white, the appetite lost, and the bowels 
often disordered. In other words, the entire constitution sympathizes 
with and suffers from the diseased condition of its central and most im- 
portant organ. 

549. Cases, however, occur in which the symptoms are much more 
obscure, nay, which may hardly indicate the region affected. My dear 
friend, the late Dr. Hunt, gave me the notes of the following case, 
which strikingly illustrates the fact: "George M'Donnell, set. seven 
months, a large healthy child, awoke screaming from sleep, about 6 A. 
M., on Monday morning. He was bathed and fomented without relief. 
On Monday Dr. Hunt saw him, and found the state of the skin, abdo- 
men, and his general appearance, natural. He drank freely, but not 
greedily, and without pain or difficulty ; pulsation of the fontanelle 
regular ; respiration high, apparently painful, but not difficult ; the alse 
nasi were not in movement, nor was there any heaving of the chest. 
After crying continuously for some minutes, he would then give two or 
three screams. This state continued until 8 A. M. of Wednesday, he 
having never slept more than a few minutes the whole time. At this 
time the pulse was scarcely to be felt, the body was cold, and the side 
on which he was lying was dark red, like the appearance of cadaveric 
congestion. This appearance, and the sinking of the pulse, were said 
to have existed from an early hour the preceding night. He died at 11 
A. M., without convulsion or struggle. Dr. Hunt was for some time 
inclined to regard it as a case of cerebral disease; but on making a 
post-mortem examination, the pericardium was found universally ad- 



390 PERICAEDITIS. 

herent to the heart by fresh lymph, except In one small space which 
•was filled with milky fluid. The lungs and pleurae were healthy." 

This case is very valuable as showing the occasional obscurity of these 
cases, and also as another instance of idiopathic pericarditis. 

550. In cases which terminate favorably, the symptoms, after con- 
tinuing a certain time, gradually diminish, the abnormal sounds become 
less and less audible, or the dulness becomes more limited and less abso- 
lute, and the child recovers its usual health. These are the most for- 
tunate cases, and their duration varies from one week to a month and 
more. 

The course of the fatal cases is much more rapid, terminating often 
in three or four days. Rilliet and Barthez mention one case of small- 
pox, which proved fatal in twenty-four hours after pericarditis set in. 

But there is an intermediate class of cases, and perhaps more nu- 
merous than either, viz : where life is saved, but a certain amount of 
injury to the heart remains permanent, requiring a long time to repair, 
even if the normal condition be ever restored. There may or may not 
be much evidence of its existence — some increase of impulse, and a 
liability to palpitate from exertion or mental emotion. Or it may give 
rise to remote consequences of more or less importance, and requiring 
great attention. Let us inquire into some of these conditions and con- 
sequences. 

551. I. In the process of cure the fluid may be entirely absorbed, 
allowing the two surfaces of serous membrane, covered by a layer of 
lymph, to come into contact, and between them adhesions may be 
formed, so complete, that the pericardial cavity shall be entirely ob- 
literated. This is almost complete reparation, as Dr. Latham remarks, 
but still it is unsound, and may lead to further evil, although this is a 
point not quite understood as yet. Dr. Latham observes, " I have, 
indeed, often met with ' this almost complete reparation, and this least 
degree of unsoundness,' appertaining to the pericardium after death, 
where inflammation had been formerly suffered. But it has been ac- 
companied with unsoundness of the endocardium also ; and further dis- 
organization, in the shape of a threatened muscular structure and a 
dilated ventricle has been superadded, and all have been notified by 
symptoms during life. 1 It is, however, very doubtful in these cases 
what share in the production of the mischief is due to the disease of the 
pericardium, and what to the endocardium. 

ir. But, instead of a close and universal adhesion of the serous sur- 
faces we may have part adherent and part free, or there may be several 
adhesions and several perforations or cavities. At first sight this would 
seem to be of no consequence, or of rather less importance than the 
former case; but this is not so, for these loose spaces are very liable 
to fresh attacks of inflammation and its results. "After death from 
secondary pericarditis, the heart has been found apparently surrounded 
with many little separate abscesses, which have turned out to be col- 

i Lectures, &c, comprising Diseases of the Heart, vol. ii. p. 111. I cannot refer to 
Dr. Latham's work without expressing my sense of its great value. I know no book 
which contains more sound medical philosophy, or more judicious practical suggestions, 
conveyed in a manner jiore simple and intelligible. 



PERICARDITIS. 391 

lections of purulent matter between the folds of the pericardium, where 
it had here and there failed to contract adhesion after a former inflam- 
mation." 

" Thus, the thought of a healthy child first seized with acute rheu- 
matism is full of sorrowful forebodings. Its heart is very likely to be 
inflamed, and it may die ; but whether it die or not, its heart is very 
likely to be damaged for life. Having had acute rheumatism once, 
though it may perfectly recover, it is very likely to have it again ; and 
whenever it again has acute rheumatism, it is very likely again to have 
inflammation of the heart as its accompaniment." 

552. The symptoms which indicate partial or complete adhesion of 
the pericardium are by no means definite. When the adhesions are 
loose and mobile, they do not interfere with the heart's actions or sounds, 
and afford no sign. When closely adherent, the heart's action is gene- 
rally exaggerated, and Dr. Hope speaks of a "jogging, or trembling 
motion," but Dr. Williams does not regard this as proving an adherent 
pericardium. He has specified one condition in which he thinks the 
diagnosis plain, i. e., when the folds of the pericardium are adherent to 
each other, and the outer one also to the walls of the chest to the left 
of the sternum. In such a case, he says, " there will be, proportionally 
to the adhesion and size of the heart, a space in which the pulsations 
are always felt, and the sound on percussion is always dull in every 
stage of respiration, and in every position of the body." 1 

553. The symptoms which mark the accession of a fresh attack of 
inflammation are likewise vague in character, though affording sufficient 
evidence that the heart is the seat. " In the first inflammation of the 
pericardium there is the exocardial murmur, made by the moving of its 
roughened surfaces upon each other. But in after inflammation of the 
pericardium, exocardial murmur there is none, and none can there be 
if its surfaces adhere completely ; and if they adhere partially, and 
there be a murmur, it will not have the proper attrition in it, and so 
will want the proper exocardial character." We must, therefore, infer 
the secondary attack from the local symptoms, without pretending to 
much exactness. Dr. Latham has given a case illustrating this, from 
which I shall make an extract, as it is too long to quote. " William 
Bean, aet. 12, was admitted into the hospital December 16th, 1833, and 
died on the evening of the 19th. His symptoms on admission were 
these : Skin hot and dry ; tongue moist and white ; pulse 140 and 
jerking ; swelling, and slight redness, and pain of the right wrist and 
hand, but of no other part of the body; breathing hurried and short, 
with a slight cough; pain in the precordial region, increased by pres- 
sure between the ribs, and by deep inspiration; excessive impulse of 
the heart ; inability to lie on the left side. Auscultation found the lungs 
admitting air freely in every part, and at a circumscribed part beneath 
the cartilages of the third and fourth ribs on the left side, the systole 
of the heart was heard, accompanied by an unnatural sound of an in- 
definite kind. The sound was lost when the stethoscope was removed 
from this spot in the least degree." The boy had had an attack of 

1 On Diseases of the Chest, p. 240. 



392 PERICARDITIS. 

rheumatism a year and a half before, with inflammation of the peri- 
cardium, and after death there was found evidence of two distinct in- 
flammations occurring at distant periods ; certain old, firm, close adhe- 
sions, and, in other parts, recent lymph deposited on the surface. 

554. in. Lastly, we may have not merely a difference in the extent 
of adhesions, hut in the quantity of uniting medium. Sometimes we 
find a thin, slight tissue interposed, in other cases one of half an inch 
in thickness ; and every intermediate degree. Now this must be an im- 
pediment, and an incurable one, to the accurate performance of the 
heart's functions, though compatible with life ; and moreover, the peri- 
cardium in this condition is peculiarly exposed to the perils of second- 
ary inflammations. 

555. iv. So much for the organic changes, the consequences of peri- 
carditis, with their dangers ; but in pericarditis we have irritations of 
other organs complicating the primary disease. For example, various 
and severe nervous symptoms sometimes arise. "Wild delirium, epi- 
leptic or tetanic convulsions, chorea, coma, fatuity, are the greatest and 
the rarest ; and muttering, reveries, transitions from torpor to excite- 
ment, subsultus, are the least and most frequent. But they are all akin 
to one another. The least may mount up to the greatest, and the 
greatest run down to the least." 1 

556. Morhid Anatomy. — The morbid changes discovered by dissec- 
tion, resemble closely those of other serous membranes ; the pleurae, 
for example. The membrane is found occasionally injected, either 
generally, giving it a pale rose color; or in patches, or resembling 
ecchymoses. Its surface is generally polished and smooth, but in one 
case Uilliet and Barthez found it thickened and rough. The increase 
of thickness generally described is probably due to the layer of false 
membrane deposited upon the serous surface, and the erosions or ulcer- 
ation, as in Schmidel's case, to depressions in this adventitious layer. 

A quantity of serum is almost always the result of inflammation. 
The amount varies a good deal ; in general it is not very abundant ; in 
children from two or three to six or seven spoonfuls. When the in- 
flammation is very intense, it will be more abundant : generally yellow- 
ish, sometimes greenish yellow, like whey mixed with flocculi of lymph. 

But besides serum there is generally a layer of false membrane on 
one or both serous surfaces, of varying thickness and tenacity, but 
more firm and dense the longer the standing of the disease. It may, 
however, be limited to one serous fold, or it may occur in patches, 
granules, or filaments, connecting the two surfaces. 

When the disease becomes chronic, the fluid is absorbed, leaving the 
false membrane as the only evidence of the pericarditis. 

Ultimately, as I have already stated, more or less intimate and ex- 
tensive adhesion takes place between the opposite surfaces of the peri- 
cardium ; but as this is rather a reparative process, we do not generally 
observe it in those who have died of pericarditis, but in those who, 
having recovered from that attack, either become victims of a second 
or of some other disease. 

1 Latham on Diseases of the Heart, p. 18. 



PERICARDITIS. 893 

In secondary attacks of pericarditis, we find the old, firm, close ad- 
hesions in some parts, whilst in others there are patches of recent 
lymph, or small collections of puriform matter. 

The irregular white patches, which are so commonly observed upon 
the pericardium of children as well as of adults, have been proved by 
Dr. Paget, to be the result of circumscribed chronic inflammation. 

Rilliet and Barthez mention having once found the interposed false 
membrane of a semi-cartilaginous character. 

557. Causes. — Pericarditis is more common, according to Rilliet and 
Barthez, in children above six years of age ; all their cases, with one 
exception, were from seven to fifteen years, and more above than below 
eleven years. Puchelt, however, quotes cases of one, two, three, and 
four years. I have seen the disease in an infant under a year old ; 
and we have had Dr. Todd's testimony that it is not unfrequent in 
infants. 

Whether sex does really influence the predisposition to the disease 
it is difficult to say; but of Rilliet and Barthez's twenty-four cases, 
twenty-one were boys and three girls. 

Puchelt attributes much influence to hereditary predisposition, and 
among direct causes he enumerates blows, falls, cold, &c. 

Billard conceives that its occurrence in young infants may be owing 
to the extra activity of the heart on assuming an independent life. 

558. But a much more important point for our investigation is the 
diseases during whose course pericarditis is most apt to occur ; in other 
words, the primary diseases to which the present affection is secondary. 
This is of unusual importance, because we find that secondary pericar- 
ditis is by far the most frequent, and if we know the diseases in the 
course of which we may expect it, we shall be prepared to detect, and 
to treat it in its earliest stage. 

I. Bouillaud considers pericarditis and endocarditis to be essentially 
a part of rheumatism in the adult ; and though Dr. Williams does not 
go so far, he states that he has found signs of one or other in three- 
fourths of the cases of severe rheumatism he has examined in the last 
six years. Dr. Latham's experience is also to the same effect, and 
such appears to be pretty much the case with rheumatism in children. 
Rilliet and Barthez found pericarditis in four cases out of eleven of 
acute rheumatism ; and Dr. West mentions it as the most frequent 
accompaniment of this disease. He adds also the following very im- 
portant practical observations : " It is of importance, however, to bear 
in mind, that the risk of cardiac mischief supervening in any case of 
acute rheumatism increases in direct proportion to the youth of the 
patient, and that the mildness of the general symptoms, the small 
amount of pain in the limbs, and the almost complete absence of swell- 
ing of the joints, afford no guarantee that the heart may not become 
the seat of the most serious disease. It happens, too, less rarely in 
the case of children than of the adult, that the general indications of 
rheumatism follow instead of preceding the heart affection; so that 
fever, with hurried circulation and distinct endocardial murmur, may 
exist for two or three days, before the occurrence of pain and the 



394 PERICARDITIS. 

appearance of swelling of the joints show that the disease of the heart 
is only a part of the great malady which has attacked the whole system." 1 

II. It may also occur in the course of infantile remittent, although, 
as in rheumatism, it is more frequently endocarditis than pericarditis. 

III. The eruptive fevers occasionally give rise to it; thus it may arise 
in the course of scarlatina, as first noticed by Yieussieux and Wells, or 
measles. 

iv. We sometimes find it apparently the result of other diseases of 
the chest, from which it may probably have extended, owing to the con- 
tiguity of the tissues affected. Thus, it is not very rare to find it com- 
plicating pneumonia and pleuritis., Dr. West mentions three such 
cases, and I have seen similar ones. 

V. It sometimes appears to be the result of morbid changes in the 
blood, caused by other and more distant diseases, as, for instance, 
Bright's disease of the kidney ; and in such cases it may arise only 
shortly before death, as in a case related by Dr. Latham. 2 

vi. I have already mentioned (129) that in chorea the heart often 
becomes the seat of secondary inflammation. 

This cursory enumeration of diseases which may be complicated by 
inflammation of the membrane of the heart, may well impress us with 
the necessity of watchfulness, and of repeatedly examining into its 
condition in all such cases. Much of our success will depend upon the 
early detection of the disease, and we may often overlook it if we wait 
until the symptoms force it upon our attention. 

559. Diagnosis. — If we trusted to symptoms alone, our diagnosis 
would be often inexact, although even then we could have no doubt of 
the existence of a very serious thoracic affection ; but when, in addition, 
we are able to examine the chest with the stethoscope, we shall gene- 
rally make out the disease correctly. The distress referable to the 
region of the heart, the hurried respiration, the difficulty of lying down, 
the exocardial murmurs, the dulness on percussion, and the increased 
impulse of the heart, are the characteristic signs and symptoms of the 
disease. 

The only diseases with which there is much danger of our confound- 
ing it are pleuritis and endocarditis. 

I. From the former it is distinguishable by the limited extent of the 
dulness, the locality of the friction sounds, and the free permeable con- 
dition of the lungs, and the resonance of all parts of the chest except 
the prsecordial region. When complicated with pleuritis, we shall have 
all the signs of each disease present. 

II. In endocarditis the symptoms are very similar, but the endo- 
cardial murmurs are essentially different, and indicate some obstruction 
to the current of the blood. But the two diseases are frequently com- 
bined, and then, in addition to the friction or crackling sound of peri- 
carditis, we have the souffle of a narrow valvular orifice. In simple en- 
docarditis there is no increase of dulness on percussion. 

560. Prognosis. — Although a very serious disease, yet pericarditis 

1 Lectures on Diseases of Infancy and Childhood, p. 304. 

2 Lectures, &c, on Diseases of the Heart, vol i. p. 358. 



PERICARDITIS. 395 

is not as frequently fatal as we might d priori suppose ; nay, a consi- 
derable number recover when the disease is partial. 

When the inflammation is acute and general, of course the danger is 
very much greater, and is aggravated by the existence of the primary 
disease; yet even of such cases a proportion recover. Rilliet and Bar- 
thez saved their four cases of rheumatic pericarditis. 

In forming our prognosis, we must take into careful consideration the 
age, strength, constitution, and previous history of the patient, with a 
due estimate of the primary disease and its effects. 

Dr. Latham has so strikingly shown the danger dependent upon the 
constitution of the child in such diseases as the present, that I need 
make no apology for extracting some of his observations: "It goes 
hard with weak, scrofulous children, and with men and women whose 
habitual health is no better than an habitual infirmity, when they come 
to suffer inflammation of any vital organ ; but it often goes still harder 
with them after the inflammation has ceased, if much be left for repara- 
tion. Subjects of this unhappy constitution will struggle through a com- 
bined attack of inflammation of the heart and lungs, and hold out well 
until it has come to an end, and will afterwards die during the halting, 
ineffectual efforts of reparation, or only after a very long time and many 
vicissitudes, will reach the point of safety at last. Their constitution 
has given all that it could to the disease without dying, and it has now 
not enough, or scarcely enough left to give for reparation, or rather for 
that degree of reparation which is needed for present safety." 

561. Treatment. — Fortunately the treatment of pericarditis is simple 
and intelligible, so that, having ascertained the nature and stage of the 
injury, we have only to bring our remedies to bear upon it promptly. 
The indications of cure are to abate the inflammation, to moderate the 
violent action of the heart, and at a more advanced stage to promote 
absorption. Each remedy I shall mention will, if successful, accomplish 
more than one of these objects. 

When called to a case of acute pericarditis, whether primary or se- 
condary, the first thing is to take away some blood, either from the arm 
or by cupping or leeching, if the child will bear it, and in proportion to 
its strength. 

If the heart disease be primary, it will bear it well, and not only once, 
but twice or three times, if necessary. If the disease be secondary, and 
the primary disease have not much reduced the child, blood must be 
taken; in almost all cases of rheumatism, for instance, there will be no 
counter-indication. 

But when the child has been run down foy measles, scarlatina, pleu- 
risy, &c, or was originally of a weak, scrofulous constitution, we must 
be more cautious ; perhaps three or four leeches may be borne, applied 
to the prjecordium, or if not, we must then depend upon calomel and 
opium, with counter-irritants. 

502. Calomel alone, or in combination with a small quantity of opium, 
squills, or digitalis, is next in value to bleeding. We should commence 
its exhibition in all cases immediately, and proportioning our dose to 
the age of the child, the state of the bowels, &c, and guarding against 
diarrhoea, we should endeavor to bring the child as quickly as possible 



396 PERICARDITIS. 

under its influence. Mercurial inunction may be used at the same time 
that calomel is given internally, and both should, if possible, be con- 
tinued until either soreness of the" gums or mercurial diarrhoea gives 
proof that the constitution is affected. 

In the first instance the mercury is employed for its antiphlogistic 
properties, but afterwards it may be continued in smaller doses, or re- 
sumed, for the purpose of removing the fluid effused into the pericar- 
dium. Dr. Latham has some valuable observations upon this subject, 
to which I gladly refer the reader. 1 

As an adjunct to these remedies, and especially for the purpose of 
quieting the inordinate action of the heart, digitalis has been recom- 
mended, and it has the additional advantage of acting as a diuretic. It 
may be given either in powder, infusion, or in tincture, but its effects 
must be carefully watched, and, if necessary, the medicine suspended. 
It is better to commence with small doses at first, say a drop or two, 
three times a day, for a child of a year old, and gradually increasing it 
according to the effects. 

The German writers recommend its combination with the calomel, or 
we may add a little squills to it by way of securing the action upon the 
kidneys. 

If digitalis cannot be borne, Rilliet and Barthez recommend the 
nitrate of potash, to which Puchelt adds Glauber's salts and cream of 
tartar, with absolute repose, low diet, and moderate warmth. 

563. Counter-irritation is of considerable value when the first acute- 
ness of the disease is subdued after bleeding, &c, and also subsequently 
to promote absorption of the fluid; and the best mode is to apply a small 
blister for a short time, and repeat it near to the former. 

The bowels must be kept free, but severe purgation should be avoided. 
Let the child be kept perfectly quiet, both mentally and corporeally ; 
there should be no attempt to enforce discipline ; and those who are in 
health may patiently bear with and humor the caprices of a child suffer- 
ing under so distressing an affection. The child must be kept in bed, 
comfortably clothed, and in the position it finds most comfortable. 

The diet must be antiphlogistic, with some modification in the case of 
children who are much worn down, or of weak constitution. 

I would most strongly advise my readers who wish to obtain a prac- 
tical knowledge of this disease to study carefully the chapter on the 
subject, in Dr. Stokes' admirable work on Diseases of the Heart, &c. 

1 Diseases of the Heart, vol. i. p. 260, et seq. 



ENDOCARDITIS. 897 



CHAPTER III. 



INFLAMMATION OF THE LINING MEMBRANE OF TIIE HEART. — 
ENDOCARDITIS. 

564. Endocarditis, or inflammation of the membrane lining the 
heart, seems more common than pericarditis, both in adults and children, 
though they are frequently combined. Rilliet and Barthez record six- 
teen cases, and in two others the disease existed, but was only disco- 
vered after death. 

The attack may be either acute or chronic, the latter fully as fre- 
quent as the former, and either primary or secondary, the latter being, 
as in the case of pericarditis, much more common than the former, and 
more frequent than primary pericarditis, according to Dr. West. 

565. Symptoms. — The phenomena which indicate the commencement 
of endocarditis, are very slight and obscure ; a slight febrile movement, 
which subsides in a little time ; the respiration somewhat accelerated, 
and possessing the peculiar character I noticed in pericarditis; obscure 
pain in the prsecordial region ; and some difficulty in lying upon the 
left side, may be all the symptoms developed; 1 on which account it be- 
comes of great moment to watch those diseases in which it is apt to 
occur, that we may detect its commencement. 

"Tn cases of acute rheumatism," says Dr. West, "you are aware of 
this danger ; you do not wait till the patient's sufferings inform you 
that the mischief has been done, but you are on the watch against the 
first threatenings of its approach ; and your sense of hearing gives you 
earlier information and surer information concerning this than all the 
other signs together. But if the same evil against which you guard 
thus sedulously in cases of rheumatism, may occur independently of it, 
and may scarcely give warning of its approach until it is almost, or alto- 
gether, too late to cure, a measure, at least, of the same precaution, 
should be observed at all times; and in no instance of febrile disturbance 
in early life, how simple soever the case may seem, should you consider 
the examination of the patient complete without auscultation. With all 
your care, there will, probably, still be cases in which the commence- 
ment of the heart affection will escape your notice ; in which you will 
accidentally make the discovery of its existence when auscultating the 
chest for some other purpose, or in which the gradual supervention of 
the signs of valvular disease will call your attention to it long after the 
ailment has become chronic. 2 

1 Rilliet and Bavtliez, Mai. des Enfans, vol i. p. 232. 

2 Lectures on Diseases of Infancy and Childhood, p. 308. 



398 ENDOCARDITIS. 

566. The physical signs are pretty decided and characteristic. The 
sounds of the heart are energetic and regular, though hardly so clear 
as usual, and with the first sound there is a bruit de soufflet, either dis- 
tinct from the contraction, or more or less masking it. It is heard 
generally in the mammary region, sometimes clearer at the apex, and 
in other cases at the base, and extending upwards, according as the 
tricuspid or mitral valves may be the principal seat of the disease. 

This endocardial murmur may be heard at the commencement of the 
attack, and, unless in those rare cases where the return to health is 
complete, the souffle will remain for a long time as evidence of an in- 
jured heart. 

As pericarditis often co-exists, exocardial murmurs may accompany 
the bruit de soufflet, indicating the complex character of the disease, 
but ceasing long before the sounds from the diseased valves disappear. 

In simple endocarditis the precordial region is not more dull on per- 
cussion than usual. 

567. But from the obscurity of the symptoms, and the slight consti- 
tutional disturbance, the disease may run on into the chronic form 
before we are consulted, and then we shall be at once presented with 
the phenomena of the disease, and of some, at least, of its consequences, 
mixed, very likely, with the symptoms of the primary disease, whether 
bronchitis, pneumonia, pleurisy, or fever. 

There is generally more or less cough, sometimes dry, in other cases 
with expectoration ; the respiration is also accelerated, partly owing to 
the primary disease, but principally to the affection of the heart. The 
breathing is panting, hurried, and as if a moment's interruption would 
be followed by suffocation. 

The pulse is always quick, small, and thread-like ; sometimes, though 
by no means always, the patient complains of pain or uneasiness in 
the region of the heart. The surface is seldom hot, although in some 
cases there are abundant perspirations. Rilliet and Barthez have not 
found the face so characteristic as in adults : sometimes the alee nasi 
were in action, and in all the countenance expressed anxiety and 
suffering. 

In some cases the child can lie on either side, but in most I think it 
requires to be propped up by pillows. 

A large proportion of cases suffer from anasarca, partial or general. 
Rilliet and Barthez met with it in nine out of twelve cases. Other and 
more distant consequences of the condition of the heart I shall describe 
presently. 

The physical signs are those which indicate injury of the valves of 
the heart, and the results of such injury, dilatation or hypertrophy, or 
both. 

The heart's action is more extensively heard than usual ; sometimes 
dull but energetic ; in others, and perhaps more frequently, clear and 
superficial. Ordinarily they are distinct, but sometimes confused and 
running into each other. 

Mental emotion or sudden movement occasions violent palpitations. 

In all cases a bruit de soufflet accompanies or immediately follows 
the first sound of the heart. Heard from the beginning, it persists 



ENDOCARDITIS. 399 

after the patient has apparently recovered, or until death, if the disease 
prove fatal. 

568. Unlike acute endocarditis, when the chronic form has continued 
for some time, there is a diminution of resonance on percussion, amount- 
ing in many cases to absolute dulness, and much more extensive than 
natural. 

The following case, given by Dr. West, affords an excellent picture 
of this form of disease : " Nothing could be more gradual than the 
advances of the early stages of the disease of the heart in the case of 
a little girl, eleven years old, who came under my notice in the month 
of March, some years ago. Her mother stated that, though not robust, 
she had never had any definite illness, but that for the last year she 
had been growing thinner, and had suffered from palpitation of the 
heart, which had by degress become more and more distressing, and 
that for the past three months she had suffered likewise from cough. 
The child, when brought to me, was greatly emaciated ; her face was 
anxious and distressed ; her breath short, so that it was with difficulty 
that she walked even a short distance. She had frequent short cough, 
without expectoration, and she suffered much from palpitation of the 
heart, and a sense of discomfort at the chest. The heart's action was 
violent ; dulness in the prse cordial region was extended ; a very loud, 
harsh, rasping sound accompanied the first sound of the heart, loudest 
towards and to the left of the nipple, but heard over the whole of the 
chest, both before and behind. Various remedies brought slight but 
temporary relief to her sufferings, and she grew worse every month. 
She became more and more emaciated; the distress at the chest and the 
palpitation of the heart increased ; her cough became more violent, and 
once she had an attack of hemoptysis. For about a month before her 
death the cough altogether ceased, but she was now altogether unable 
to leave her bed from increasing weakness ; the palpitation continued 
unmitigated, and her extremities became slightly anasarcous. During 
the last week of her life, her respiration was extremely difficult, and 
became increasingly so till she died on the 10th of October. 

" The lungs were very emphysematous, and much congested, but 
not otherwise diseased. The heart was extremely large, but its right 
cavities did not exceed the natural size. The pulmonary valves were 
healthy, the edges of the tricuspid valve were slightly thickened ; the 
left auricle was enormously dilated, but its walls were not all attenu- 
ated ; the pulmonary veins were much dilated ; the left ventricle was 
dilated, its walls were thickened; the chordae tendineae of the mitral 
valve were greatly shortened, so that the valve could not close ; the 
valve itself was shrunken, thickened, and cartilaginous ; and there 
existed likewise a slight thickening of the edges of the semilunar valves 
of the aorta." 1 

569. Such or such like is the history of those cases of endocarditis, 
which, giving rise to injury of the valve and consequent hypertrophy, 
run a fatal course within the space of some months: incipient obstruc- 
tion to the circulation, constant dyspnoea, palpitation, exhaustion, ema- 

1 Lectures on Diseases of Infancy and Childhood, p. 309. 



400 ENDOCARDITIS. 

ciation, and death. But all do not necessarily thus terminate. The 
patient may recover, i. e., her life may be saved, with an injured heart, 
and in this exact condition it may remain for five or six years, neither 
improved nor getting worse, suffering from palpitation, dyspnoea, and 
some pain on exertion or mental emotion. " The child who has had 
the precordial murmur ever since it suffered a certain rheumatic attack, 
is just the same child it was before, except that it cannot join in any 
pastime requiring rapid movement, for then its heart palpitates, it loses 
its breath, and is obliged to sit down." 1 Dr. Latham adds: "I have 
lately seen a young lady, thirteen years of age, whom I attended three 
years and a half ago, under an attack of acute rheumatism attended 
by endocarditis. The symptoms during the attack referable to the 
heart were completely characteristic of the disease, and carried to such 
extremity as to keep life in peril for several days. It was, perhaps, the 
severest case I ever saw recover. She did recover, however, but never 
lost the murmur and occasional palpitation. At present she has the 
appearance of perfect health ; she even bears the marks of premature 
womanhood. She goes to school, plays about like other girls, but can- 
not run so fast or so far as the rest, or use bodily exertion beyond a 
certain amount, without dispnoea and palpitation, and some pain in the 
region of the heart. For all other purposes she is absolutely well. In 
examining the state of her heart when she is quite free from all excite- 
ment, I find no extraordinary impulse either of extent or of degree. 
It is felt only at the apex. Neither do I find any extraordinary extent 
of dulness on percussion. A systolic murmur is audible everywhere 
within the precordial region, most audible at the apex, more faintly at 
the base. From the basis upwards towards the right clavicle, in the 
course of the aorta and subclavian artery, it is entirely lost ; towards 
the left clavicle, and in the course of the pulmonary artery, it is very 
loud, but not at all hard in the carotids. From the apex the murmur 
extends far round towards the left axilla and the back. Here I pre- 
sume that the rheumatic inflammation has done a permanent injury to 
the endocardium on both sides of the heart, and that the mitral valve 
and the semilunar valves of the pulmonary artery have undergone 
change of structure." 

The same author mentions the case of two young ladies in whom 
similar evidence of valvular injury had existed from childhood, but 
whose health has never suffered in consequence, and he asks : " Do not 
these facts give intimation of a certain protective power, probably in- 
herent in the growing heart, whereby it can accommodate its form and 
manner of increase to material accidents, and to repress or counteract 
their evil tendencies ?'■' 

I have a little patient in whom I accidentally detected a bruit de 
soufflet with the first sound of the heart some years ago, without being 
able to trace the disease to its commencement. Like Dr. Latham's 
case, his health does not appear to suffer, and the heart disease remains 
stationary. 

570. Consequences. — But this is far from being the general result of 

1 Latham on Diseases of the Heart, vol. ii. p. 89. 



ENDOCARDITIS. 401 

such cases. There are certain consequences which seem to he the ne- 
cessary effect of permanent disease of the valves from endocarditis. 

I. I should first mention, however, that the lining membrane of the 
heart, once having been the seat of inflammation, seems as liable as the 
pericardium to a repetition of the attack; with this difference, however, 
that the signs indicating it, the palpitation, dyspnoea, impossibility of 
lying down, strong impulse, and loud murmur, are much more charac- 
teristic and definite than those of secondary attacks of pericarditis. 
Both Dr. Latham and Dr. West mention cases of this kind, with a 
melancholy foreboding of the future history of such cases. " The val- 
vular disease, and the heart's efforts to overcome its consequences, have 
already led to a considerable degree of hypertrophy of the organ ;- the 
danger of each acute attack will be aggravated by the old disease, and 
every fresh inflammatory seizure will add to the chronic mischief, until, 
in the course of time, the disorganization of the heart will have ad- 
vanced so far as to render it unable to perform its office sufficiently well 
to maintain existence any longer, and a life of suffering will then be 
closed by a painful death." 

II. Attenuation and softening of the left ventricle, either alone or 
combined, may be the result of valvular disease, giving rise to a feeble 
impulse but loud sounding action of the heart, and to other and deeper 
derangements of the circulation, near or distant, and of a passive cha- 
racter, such as effusions of serum or blood, congestions, &c. 

III. But a more common result, with children at least, is the produc- 
tion of hypertrophy with dilatation, i. e. when the substance and size 
of the heart are both increased, the cavities, or some of them, are larger 
than natural, and the walls are thicker. The left ventricle and auricle 
are most frequently the seat of this morbid change. 

There can be no doubt that it is the result of valvular injury, and that 
it is a kind of reparation at the same time ; an obstacle existing to the 
passage of the blood, an increase of force is required by the heart to 
overcome it, and to prevent the consequences of such interruption. 

" A loud, systolic, endocardial murmur, and an excessive impulse of 
the heart, and a larger space of precordial dulness than natural there, 
are the sure and authentic signs of an injured valve, and hypertrophy 
of the left ventricle." 1 But the rhythm of the heart's action may be 
perfectly regular, and the pulse betray no sign of the existing mischief. 
The general circulation, too, may be perfect, and the color and heat of 
surface quite natural. 

But although in itself, and to a certain extent, a process of repara- 
tion, this augmentation of size and force may become a deadly evil in its 
result. The most common effect of this state of the heart is the effusion 
of serum into the cellular membrane, first of the lower extremities, then 
of the body, upper extremities, and face. In some cases, similar effusion 
may take place into the serous cavities with alarming results. 

Again, a child laboring under hypertrophy of the heart is liable to 
congestion, hemorrhage, or inflammation of different and distant organs, 
of an active character, and attended by very serious consequences. The 

1 Latham on Diseases of the Heart, vol. ii. p. 296. 

26 



402 ENDOCARDITIS. 

same diseases apparently as those from attenuation, but of an opposite 
character, and requiring a different treatment, they seem, upon the 
■whole, more manageable. 

571. Morbid Anatomy. — The morbid changes from endocarditis are 
not so numerous nor so marked as in other serous membranes, for the 
very obvious reason that the current of blood must sweep away with it 
all the serum which may be effused, and a great portion of the lymph ; 
still, enough remains to afford evidence of the disease, now that we know 
what to seek for. On opening a heart which has suffered from this dis- 
ease, we find the lining membrane vascular, and of a red color gene- 
rally, or in parts when the inflammation is recent. A certain amount 
of coagulable lymph is deposited upon the valves, either in patches or 
like small beads. The mitral valve is the most frequent seat of these 
depositions, then the tricuspid. At a later period, there may be no vas- 
cularity nor any traces of recent lymph, but the valves are thickened, 
irregular, retracted, or incomplete, sometimes cartilaginous, and occa- 
sionally, but rarely, osseous. Now and then there are vegetations upon 
them, or the chordae tendineas may be shortened. Whatever be the pe- 
culiar modification of the lesion, the effect is to render the valves less 
pliable, less capable of closing the orifice, or of yielding to the current 
of the blood ; hence the endocardial murmur, and the remote conse- 
quences of obstructed circulation. 

When the valvular disease is of old standing, we may find hypertro- 
phy and dilatation about equally frequent, according to Rilliet and Bar- 
thez, who also mention that they have found the hypertrophy limited to 
the inter-ventricular septum, and to the columnse carneas in connection 
with diseased valves. 1 The tissue of the heart is almost always in its 
normal condition, red and firm. In one case only, Rilliet and Barthez 
found it soft, flaccid, and of a yellowish red. 

572. Causes. — It is extremely difficult to specify the causes of endo- 
carditis, except in general terms, inasmuch as we see so little of the 
disease except as a secondary affection. It does not appear that either 
age or sex have much if any predisposing influence. Of eighteen pa- 
tients mentioned by Rilliet and Barthez, affected with acute or chronic 
endocarditis, the numbers of boys and girls were equal. 

It is as a secondary disease, however, that its principal interest con- 
sists, and the primary affections in which it occurs are the same as those 
enumerated when speaking of pericarditis, with which it is very often 
combined. 

I. The most common primary disease is acute rheumatism, at any 
stage of which the heart may become affected. We may easily detect 
its invasion, if we are on the watch. The increase of the heart's action, 
the hurried respiration, the anxiety of countenance, and the endocardial 
murmur, will at once indicate the new and formidable enemy with which 
we have to grapple. 

II. I have seen it come in the course of infantile remittent quite sud- 
denly. A few hours before, the child was going on very well, without 

1 Mai. des Enfans, vol. i. p. 220. Dr. Hope on Diseases of the Heart, 3d ed., p. 203, 
et seq. 



ENDOCARDITIS. 403 

any local affection, when, suddenly, dyspnoea, very quick pulse, pain in 
the chest, and bruit de soufflet, made their appearance. 

III. In like manner, we may find it complicating any of the eruptive 
fevers, especially scarlatina and measles, when we least expect it, and 
without any warning. On this account, let me repeat the advice already 
given, to look carefully to the heart at each visit in all these diseases. 

The hypertrophy and dilatation result naturally, and to a certain 
extent as a reparative process, from the obstruction offered to the circu- 
lation, and the necessity of an increase of force to overcome it. Rilliet 
and Barthez mention that deformity of the chest (from rachitis) may 
give rise to hypertrophy, as it certainly may to considerable confusion 
in the heart's sounds. 

573. Diagnosis. — There is perhaps less difficulty in the diagnosis of 
endocarditis than of pericarditis, and there is not much danger of their 
being confounded. We may certainly overlook either when both are 
combined, but practically this would not be of much consequence. 

The general symptoms are much the same, but the presence of endo- 
cardial murmurs, the bruit de soufflet, de scie, and de rape, with the 
first chiefly, or with both sounds of the heart, and the absence of the 
friction sound, will render the diagnosis clear. At an early stage, 
the dulness is less absolute and less extensive in endocarditis, and the 
patient suffers more from palpitation. In the chronic stage, we have 
the murmurs, an increase of dulness, oedema or anasarca, with palpita- 
tion upon the least exertion. 

There is a class of cases among adults which seems a little puzzling 
at first. I allude to those in which bruit de soufflet and other murmurs 
are heard in the heart and large vessels, not from valvular disease, but 
from some change in the component parts of the blood, e. g., in patients 
in a state of angemia. This I have often found in women laboring under 
amenorrhoea ; but we have the satisfactory testimony of Dr. West that 
it is not the case with children under seven years of age, and that at a 
later period it is very rare. 

574. Prognosis. — The prospects of the patient are always very seri- 
ous and doubtful. They may recover from immediate danger, and life 
may be safe for the present, and even, in some rare cases, for years; 
but sooner or later, it is to be feared that some of the consequences I 
have enumerated will either terminate life or render its continuance a 
burden. 

575. Treatment. — The treatment of endocarditis is almost identical 
with that of pericarditis. When acute, bleeding, general or local, 
calomel, digitalis, and diuretics, with counter-irritation subsequently, 
are all the means at our disposal. As I have entered fully upon their 
employment in pericarditis, there is no occasion to do so now, as what 
was then said applies to the present disease just as well. 

The necessity for absolute quiet is even greater, or, at least, more 
obvious, in endocarditis ; for mental emotion, disturbance, or exertion, 
increase the dyspnoea and palpitation to a most distressing degree. 

576. A second attack of inflammation must be met in the same way, 
but, perhaps, less actively, according to the condition of the patient, 
and certainly with less hope of being successful. 



404 ENDOCARDITIS. 

Whether any means at our command are sufficient to arrest or con- 
trol the hypertrophy and dilatation is at least doubtful, but by judicious 
regimen we may often prevent inconvenience, and by timely and well- 
considered treatment may relieve some of the consequences, such as 
anasarca, local congestions, &c. Diuretics for the removal of effu- 
sions, calmants for tranquillizing the action of the heart, and local 
antiphlogistics in moderate degree, will at least afford a chance of 
relief, and of the prolongation of life. 



SECTION IV. 

DISEASES OF THE DIGESTIVE SYSTEM. 



CHAPTER I. 



INTRA-UTERINE DISEASES.— CONGENITAL MALFORMATIONS. 

577. A considerable variety of intra-uterine diseases of the digest- 
ive system have been observed and recorded. Thus Orfila, Veron, 1 
Cruveilhier, 2 Billard, and others, speak of muguet observed at birth, 
and evidently existing during intra-uterine life. Cases of oesophagitis 
have been mentioned by Billard 3 and Orfila ; of gastritis by Siebold, 4 
Billard, and Orfila ; of peritonitis and enteritis by Weisberg, 5 Chaus- 
sier, 6 Veron, 7 Duges, 8 Billard, Canes, Cruveilhier, 9 Simpson, 10 and 
others. 

Numerous cases of infants born jaundiced are on record. Some of 
the mothers had jaundice, others bowel complaints, &c. Panarola, 11 
Kerkring, 12 Schurig, Schultz, 13 Wrisberg, 14 Sentin, 15 Billard, and others, 
have described such cases. 

Billard 16 has seen tubercular granulations, and Orfila mentions that 
the liver is occasionally hypertrophied, fatty, tuberculous, transposed, 
softened, or indurated. 17 

It is enough for my purpose thus slightly to prove the existence of 
morbid actions in utero, analogous to those observed in after life, thus 
completing the circle of disease. With those whose effects continue 
after birth, and with certain malformations or arrests of development, 
affecting as they do the comfort or even the life of the child, I must 
enter more into detail. I shall, in the remainder of the chapter, notice 
hare-lip and cleft palate, which are arrests of development, and imper- 
forate anus, which is a malformation. These are of too much import- 

1 Seance de l'Acad. Roy. de Med., June 28, 1825. 

2 Anat. Pathol., liv. 15, p. 13. 3 Mai. des Enfans, p. 274. 

4 Journal fur Geburtshiilfe, vol. v. 

5 Dissertatio de prteternaturali et raro intestini recti cum vesicae urinarise coalitu, &c, 
1779. 

6 Bull, de la Faculte de Med. 1821, vol. x. 

7 Recherches des Mai. des Nouveaux-nes, 1821. 

8 Gynsecologie, vol. ii. p. 251. 9 "Anat. Pathol., liv. xv. pp. 2, 3. 
10 Edin. Med. and Surg. Journal. 1! Obs. Med. Pentecost., p. 137. 

12 Spicilegium Anat. Obs., 57. 's M. N. C. Dec. 1. An. 6, 7, p. 355. 

14 Descriptio Anat. Embryon., 1764, Obs. 1. 

15 Beitrage zur ausiibenden Arzneiwissenscbaft, vol. i. p. 29. 

16 Mai. des Enfans, p. 421. 17 Graetzer Krankheiten des Fotus, p. 155. 



408 INTRA-UTERINE DISEASES. 

ance to be omitted, although the reader will find them fully treated in 
every systematic work on surgery. For most of the information I have 
been indebted to Mr. Cooper's invaluable Dictionary. 

578. Hare-lip. — This congenital deformity consists of a perpendi- 
cular or oblique division of the upper lip, either directly below the sep- 
tum of the nose or one of the nostrils. The upper lip, thus divided, is 
generally movable, but in some ; cases the two portions are closely 
attached to the alveolar process. The space between the divided por- 
tion varies ; sometimes it is considerable, in other cases but slight. But 
the cleft is occasionally double, constituting what is called " double 
hare-lip," and in such cases we find a small portion of the lip in front 
between the fissures. 

In a great many cases the arrest of development is confined to the 
lip ; in other cases it extends along the soft parts of the palate even to 
the uvula ; and in others the bones of the palate are incomplete. Again, 
the jaw may be incompletely ossified in front, leaving a cleft between ; 
or one portion may project more than the other. The lower lip may 
also be affected, but this is a very rare malformation. 

Every one, probably, has witnessed the deformity occasioned by the 
simplest form of hare-lip, which is much aggravated when it is double. 
But there is more than deformity resulting, for it often hinders an in- 
fant from sucking, and at a later period interferes with the facility and 
perfection of speech. All these evils are greatly worse when the lower 
lip is fissured, and even the health may suffer. 

579. Treatment. — It is evident that this deformity can only be reme- 
died by a surgical operation; and as all mothers are naturally anxious 
to have it relieved as soon as possible, the first question relates to the 
age at which the operation should be undertaken. 

The earlier the age at which it can be done safely the better, but then 
it must be remembered that very young infants are very liable to con- 
vulsions, and on this account it is generally deferred until the child is 
about two years old. Sir Astley Cooper sanctioned this, having known 
a fatal result from operating earlier. Mr. Cooper mentions having suc- 
cessfully operated upon a child five months old, and upon another a year 
old. Le Dran, B. Bell, and others, operated upon infants even at ear- 
lier ages; and Dupuytren has fixed upon three months as the most 
favorable age. 1 

My friend, Surgeon Smyly, who has had great experience in this 
operation, has favored me with the following note illustrating the point 
in question: — 

" The infant on whom you saw me operate for hare-lip was two 
months old. I removed the needles the third day ; I, however, applied 
adhesive plaster, to prevent accidents. The child has been able to suck 
well since. In cases of single hare-lip I always prefer operating early ; 
the operation is much easier of performance, as the child can make no 
resistance, the wound heals faster, and deformities of the nose and palate 
are more easily redressed when the patient is very young, and before 
teething has commenced. I have looked over the notes of some cases : 

1 Clin. Chirur., vol. iv. p. P0. 



HARE-LIP. 407 

one, the youngest I ever operated upon, was only a fortnight old, the 
others from one to four months. In none of them have I seen any un- 
pleasant symptom to deter from operating early. 

" I never saw convulsions follow in any case operated upon for hare- 
lip, and hemorrhage is as easily controlled in the young infant as in an 
older child. I generally take the precaution of compressing the coro- 
nary arteries with Dieffenbach's forceps. In looking over my notes I 
was surprised to see so many cases in which the cleft was on the left 
side, i. e. in three-fourths of the cases." 

Dr. O'B. Bellingham, Prof. R. Smith, and others, agree with Mr. 
Smyly in preferring an early age for the operation, but other sur- 
geons of this city, I am informed, prefer a later period. 

580. Whatever be the time chosen for operating, all surgeons are agreed 
that the object is to reduce the fissure to the condition of an incised 
wound, by removing the edges of the divided portions, and keeping them 
in contact until adhesion takes place. There has been some difference 
of opinion as to whether this approximation should be effected by sutures 
or by adhesive plaster and bandages. M. Louis offered a weighty oppo- 
sition to the sutures, but notwithstanding, the twisted suture is now 
generally used. "No modern surgeons doubt that a hare-lip may be 
cured by means of adhesive plaster and uniting bandages quite as per- 
fectly as with a suture ; and all readily allow that the first of these 
methods, as being more simple and less painful, would be preferable to 
the latter, if it were equally sure of succeeding. But it is considered 
far more uncertain in its effect. To accomplish a complete cure, the 
parts to be united must be maintained in perfect contact until they have 
contracted the necessary adhesion, and how can we always depend upon 
a bandage for keeping them from being displaced ? What other means, 
besides a suture, afford in this respect perfect security?" 1 

When about to perform the operation with the twisted suture, we 
should first examine whether the lip be adherent to the gum, and if so 
they must be separated by the knife. When the frenulum is in the way 
of the operation it must be divided. " In the operation for single hare- 
lip," says Mr. Cooper, " the grand object is to make as smooth and even 
a cut as possible, in order that it may more certainly unite by the first 
intention, and of such a shape that the cicatrix may form only one 
narrow line. Hence in this country the edges of the fissure are cut off 
with a sharp knife. One plan is to place any flat instrument, such as a 
piece of horn, wood, or pasteboard, underneath one portion of the lip, 
and then, holding the parts stretched and supported on it, to cut away 
the whole of the callous edge. Another is to hold the part with a pair 
of forceps, the under blade of which is much broader than the upper 
one ; the first serves to support the lip, the other contributes also to 
this effect, and at the same time serves as a sort of ruler for guiding the 
knife in an accurately straight line. When the forceps are preferred, 
the surgeon must of course leave out of the upper blade just as much of 
the edge of the fissure as is to be removed, so that it can be cut off with 
one sweep of the knife. This is to be done on each side of the cleft, 

1 Cooper's Surgical Dictionary, p. 656. 



408 CONGENITAL MALFORMATIONS. 

observing the rule to make the new wound in straight lines, because the 
sides of it can never be made to correspond without this caution." In 
University College Hospital the margins of the fissure are usually re- 
moved by transfixing the lip with a long, sharp-pointed, narrow bis- 
toury, just above the upper end of the cleft, and then cutting towards 
the red portion of the lip, while the part is held and stretched out by 
the surgeon himself or his assistant. One side of the cleft is thus pared 
off, and then the other, particular care being taken to remove a small 
piece of the red part of the lip on each side, lest an ugly notch should 
be left in that situation. This is the plan ordinarily followed by Mr. 
Liston. 

In France the edges of the fissure are always taken off with a pair 
of strong, sharp long-handled scissors, invented for that purpose by M. 
Dubois. 

Two silver pins, made with steel points, which admit of an easy 
removal, are next to be introduced through the edges of the wound, so 
as to keep them accurately in contact, the lowest pin being introduced 
the first, near the inferior termination of the wound, and the upper pin 
afterwards, about a quarter of an inch higher up. A piece of thread is 
then to be repeatedly wound round the ends of the pins, from one side 
of the division to the other, first transversely, then obliquely, from the 
right or left end of one pin above to the opposite end of the lower one, 
&c. Thus the thread is made to cross as many points of the wound 
as possible, which greatly contributes to maintaining its edges in even 
apposition. Lastly, the steel points of the pins are to be taken off, or 
if not made to slide off, they are to be supported by small dossils of 
lint, placed between them and the skin. In the University College 
Hospital Mr. Liston employs largish common needles, the heads of 
which have been dipped in sealing wax, and after they have transfixed 
the lip, he takes off their points with a pair of cutting forceps. " In- 
stead of pins made with steel points, Dr. Barton, of Philadelphia, pre- 
fers using a piece of iron wire, with a point made by simply cutting it 
with a pair of scissors. Thus he avoids the risk of the steel point 
slipping off the pin and remaining within the lip." "It is obvious 
that a great deal of exactness is requisite in introducing the pens, in 
order that the edges of the incision may afterwards be precisely applied 
to each other. For this purpose some surgeons previously place the 
sides of the wound in the best position, and mark with a pen the points 
at which the pins should enter and come out again. The pins ought 
never to extend more deeply than about two-thirds through the sub- 
stance of the lip, and it would be a great improvement always to have 
them of a flat instead of a round shape, and a little curved, as this is 
the course which they naturally ought to take when introduced. The 
steel points should also admit of being easily taken off when the pins 
have been applied, and perhaps having them to screw off and on is the 
best mode, as removing them in this way is not so likely to be attended 
with any sudden jerk, which might be injurious to the wound, as if 
they were made to pull off. In general the pins may be safely removed 
in about four days, when the support of sticking plaster will be quite 
sufficient. After the operation, compresses and a bandage for keeping 



HARE-LIP. 409 

forward the cheeks are sometimes employed, but they may in general 
be dispensed with, because irksome to children, and the occasion of rest- 
lessness. 

This is what is called the twisted suture, and is the most generally 
used for hare-lip ; but there are other circumstances and other modes of 
operating which require a moment's notice. 

581. It occasionally happens that there is a considerable projection 
of the upper jaw (especially when the hard palate is divided), sufficient 
to offer a serious obstacle to the union of the two portions of the lip. 
The ordinary practice has been to remove this portion, but as that de- 
stroys the harmony of the upper and lower jaw, it has been proposed 
and practised successfully by Desault, Dunn, and others, to employ 
compression first so as to reduce the prominence, to its proper level, and 
then operate for the hare-lip. M. Gensoul in a case seized the pro- 
jection with a strong pair of forceps, and brought it down into its place 
by main force. 

" M. Dupuytren had a peculiar method of operating in some cases 
of complicated hare-lip. He observed that when the labial tubercle 
was inserted very close to the point of the nose, its union to the lateral 
parts drew the lip upwards, and exposed the gums and teeth, while the 
nose itself was pulled clown and flattened in a most ugly manner. 
Hence he conceived that it would be better to employ the labial tuber- 
cle in forming the lower part of the partition of the nose, and to unite 
at once the lateral portions of the lip. He first divided with a bistoury 
the fold of mucous membrane uniting the labial tubercle to the osseous 
one, and then, with a pair of cutting forceps, removed all such por- 
tions of the latter as projected beyond the anterior level of the jaws. 
He next pared off the sides of the cutaneous tubercle and its lower 
edge. These things having been clone, the vertical margin of the fissure 
on each side was cut off with a pair of scissors. The two lateral por- 
tions of the lip were now brought together and united with two pins ; 
and the fresh cut bleeding middle tubercle was laid over the bony par- 
tition of the nostrils, of which it was to form the lower portion. A 
third pin was applied, so as to include at once the upper end of each 
part of the lip, and the loose extremity of the reflected tubercle. 
Lastly, two interrupted sutures united the angles of this tubercle to the 
lateral portions of the lip. The sutures were assisted with straps of 
adhesive plaster and a bandage that made pressure on the apex of the 
nose, so as to keep the flap from being too much stretched." 1 

Instead of the twisted suture Sir Astley Cooper preferred the com- 
mon interrupted suture, on account of the danger of separating the new 
adhesions when withdrawing the pins. The threads of the common su- 
ture can be cut and easily removed. When the hare-lip is double, the 
operation is the same in principle, and had better be completed at once 
instead of making two operations, as the older surgeons advised. 

Occasionally hare-lip is complicated with cleft palate, and now and 
then, after the hare-lip is cured, this fissure closes ; in other cases there 
must be some artificial substitute contrived. This brings us to the second 
of the malformations. 

1 Cooper's Dictionary, p. 657. 



410 CONGENITAL MALFORMATIONS. 

582. Cleft Palate. — There are three degrees or forms of this con- 
genital malformation: first, when the fissure is simple, and confined to 
the soft palate ; secondly, when there is a partial division of the bony- 
palate; and thirdly, when this division involves a greater or less inter- 
space between the lateral portions, and almost always a fissure in the 
alveolar process and the upper lip. The operation for each respectively 
has been termed staphylorrhaphy, staphyloplasty, and uranoplastic. 

583. I. Staphylorraphy. — Mr. Cooper describes MM. B,oux's and 
Berard's, Mr. Smith's, and Mr. Liston's method of performing this 
operation. 

In M. Roux's plan, the apparatus required consists- — I. Of three 
broad flattish ligatures, composed of three or four strong threads. 2. 
Of six small, curved, flat needles, two for each ligature. 3. A porte- 
aiguille. 4. A pair of dressing forceps. 5. A probe-pointed bistoury. 
6. Scissors with long handles and short blades, bent laterally to an 
obtuse angle. 

" The patient being seated opposite the light, and the mouth kept 
open, the surgeon takes hold of the right edge of the fissure with the 
forceps held in his left hand, while with the right he conveys into the 
pharynx the porte-aiguille armed with a needle, the point of which is of 
course turned forwards. The point of the needle is then carried back 
to the posterior surface of the velum, and passed through it from behind 
forward near the lower end of it, and about three or four lines from the 
margin of the slit. The point of the needle is to be passed out as far 
as practicable, and then taken hold of with the forceps. The porte- 
aiguille being now removed, the needle is drawn into the mouth with the 
forceps, and along with it the ligature with which it is threaded. After 
the patient has recovered his tranquillity, and washed out his mouth, the 
other end of the ligature is to be passed in a similar way through the 
left side of the velum, and the two ends are to be brought out at the 
commissures of the lips. Then a second ligature is to be applied near 
the angle where the two sides of the velum meet, and a third at the 
middle point between the other two ligatures. The left side of the 
fissure is then seized, depressed, and rendered tense with the ring- 
handled forceps, and the excision of its margin begun with the curved 
scissors, and completed with a straight probe-bistoury applied on the 
outer side of the forceps, and with its back directed towards the root of 
the tongue. Thus a slip is to be removed about half a line in breadth. 
Particular care must be taken to let the slip extend a little above the 
front angle of the fissure. The same proceedings are to be followed on 
the opposite side, the two incisions being made to join at an acute angle 
above the point just now specified. It only remains to tie the ligatures. 
The surgeon begins with the lowermost one, which is first to be tied in 
a simple knot. As soon as this has been duly tightened with the fore- 
finger, it is to be taken hold of with the ring-handled forceps, and kept 
from slipping until another knot is made. The same plan is to be 
adopted with the two upper ligatures. Finally the ends of each liga- 
ture are to be cut off as useless." 

No other dressing is requisite: the patient must avoid all exertion of 
the part, such as laughing, talking, sneezing, and even swallowing, as 



CLEFT PALATE. 411 

much as possible. The upper ligatures may be removed on the third or 
fourth day ; the lower ones should remain a day or two longer. If the 
union be not complete, the edges may be touched with the nitrate of 
silver. 

584. M. Berard's method is apparently more simple. With the left 
hand he seizes the left border of the fissure with a tenaculum, and with 
the right he passes a curved needle, held by the forceps and armed with 
a ligature, from before backwards, on a level with the upper angle, until 
its point can be seized with the forceps when it is drawn through. 
Another ligature is passed in like manner through the opposite edge, 
and as many ligatures are thus inserted as the fissure requires, and then 
the edges of the fissure are removed and the ligatures tied. 

■585. Mr. N. R. Smith, of the United States, employs a curved needle 
mounted on a handle, and armed with a ligature. The front of the 
needle is passed from behind forward until the ligature appears, and 
can be seized with a tenaculum and drawn through. The needle is then 
withdrawn, and passed through the other side of the fissure. After a 
sufficient number of ligatures have been inserted, the sides of the velum 
are to be tightened by means of them, and the edges removed by scissors 
or knife. The ligatures are then to be tied. 

586. Mr. Liston's method is as follows: "A narrow, sharp-pointed 
knife, held by the further end of the handle, is introduced through the 
edge of the fissure at its anterior margin, and run back to the apex of 
the one-half of the uvula. This may be laid hold of, and made tense 
by means of the sharp-pointed forceps. The same proceeding is re- 
peated on the other side." The ligatures are introduced with needles 
fixed in handles, and of different sizes and curvatures, the eyes being 
near their points. They are passed through the velum about a quarter 
of an inch from its free edge and towards it, and through two-thirds of 
its thickness. Each needle carries a double ligature, the noose of which 
is caught by a blunt hook and pulled out into the mouth, while the in- 
strument is withdrawn. A second and smaller ligature is carried through 
opposite to the first, and by means of this second thread the first and 
double one is brought through. By a repetition of this plan two, three, 
or more points of interrupted suture are made. After the edges have 
been brought together by one or two points, no difficulty will be expe- 
rienced in carrying others through both edges by means of a more 
curved instrument in a handle, or by the use of a small needle carried 
in the points of a pair of strong and well-fitted forceps. Before the 
ligatures are finally secured, the parts being put upon the stretch, an 
incision should be made on each side towards the alveolar ridge, through 
the anterior surface of the velum. By this method Mr. Liston finds 
that the edges may be more easily brought together, and the strain is 
taken off the threads, so that there is less risk of their making their 
way out by ulceration. Mr. Liston deems the operation very liable to 
failure. 1 

In two cases upon which Sir Philip Crampton operated in the year 
1842, that distinguished surgeon deviated from the ordinary mode of 

1 Cooper's Surg. Dictionary, p. 1078. Liston's Practical Surgery, p. 472. 



412 CONGENITAL MALFORMATIONS. 

securing the ligatures, and from the usual treatment subsequently. Mr. 
Hamilton, who relates the cases, observes: "The difficulty of tying the 
second knot on the ligature without suffering the first to become opened 
by the strong retraction of the edges of the fissure, effected by the mus- 
cles of the palate, has always been acknowledged. This difficulty, 
however, was effectually removed by an ingenious suggestion of Mr. 
M' Clean's, of Stephen's Green. After the ligatures had been passed 
through the palate at the distance of one quarter of an inch from the 
cut edge of the fissure, and brought out at the mouth, their ends were 
passed through a small perforated metallic bead, such as are used in 
making purses. The bead was then pushed down along the ligatures, 
closing them as it descended, until it touched the approximated edge of 
the wound ; it was then compressed by a pair of strong, blunt-pointed 
forceps, and the ligatures were thus firmly secured, without a knot, at 
the required degree of tension. The other and most important peculi- 
arity in the treatment consisted in allowing the patient an ample supply 
of soft food during the whole period of the treatment. Boiled bread 
and milk, custard, soup, and jelly, were given twice or thrice a day, 
and the patients were not confined to their beds." 1 

587. Professor Fergusson, of King's College, London, has proposed 
a modification of this operation, founded upon a more careful investi- 
gation of the anatomy of the parts. 2 He regards the action of the 
levatoves palati and the palato-pharyngei muscles as an obstacle to the 
closure of the fissure, and he proposes to obviate this retraction by 
dividing these muscles. " ; As a preliminary step to the ordinary ope- 
ration, I suggested the division of the levator palati on each side, and 
also, if it seemed needful, of the posterior portion of the fauces, whereby 
large portions of the palato-pharyngei might be cut across. I also then 
thought that the anterior pillars, each containing the palato-glossus, 
might possibly require division. To effect these different incisions, I 
used a small peculiarly curved blade for the levator muscle, and common 
curved scissors for the others." 3 Mr. Fergusson prefers a free incision 
through both mucous membrane and muscle. "I still retain the opinion 
that there is no better mode of introducing the stitches than by means 
of a slightly curved needle set in a handle. The point of the instru- 
ment, armed with a smooth round waxed silk thread, is passed from 
below upwards, about a quarter of an inch from the cut margin of the 
fissure, and made to appear in the middle of the gap, when the thread 
is seized with the forceps, drawn three or four inches out of the mouth, 
and then the needle is withdrawn. A similar manoeuvre is followed on 
the opposite side. The two threads are then tied together by the ends 
which have been thus drawn out of the mouth, and by withdrawing one 
of them the other will be carried through the aperture opposite to that 
where it was first introduced. Hitherto, the thread has been double ; 
now one end must be drawn through the apertures and out at the mouth, 
and so the thread is ready to be tied. Two, three, four, or five threads 
are introduced in this way, and then, after the cut margins of the flaps 

1 Dublin Journal, Jan. 1843, p. 324. 

2 Trans, of Royal Med. and Surg. Society, vol. 27. Practical Surgery, p. 530. 

3 London Journal of Medicine, No. 1, p. 21. 



IMPERFORATE ANUS. 413 

are sponged free of blood and mucus, the various threads are fastened." 
Mr. Fergusson prefers " a moderate degree of tightness, rather than 
that the edges should be kept asunder by saliva or mucus." He also 
agrees with Sir Philip Crampton in allowing the patients the use of fluid 
food. 

In Roux's experience, two-thirds of the simple cases, and one-third 
of the complicated, derived benefit from the operation. Dr. Mutter, of 
Philadelphia, succeeded in nineteen out of twenty-one operations ; Dr. 
J. M, Warren, of Boston, in thirteen out of fourteen ; Mr. Fergusson 
has given a notice of twenty-four cases, in which the operation was 
performed according to his suggestions, in twenty-one of which it was 
successful. 1 

588. Staphyloplasty. — Dieffenbach's method of performing this ope- 
ration consists in making an incision along the palate on each side of the 
fissure, and afterwards drawing the edges together by ligatures. 

" The Indian staphyloplasty consists in raising up a flap of soft parts 
from the roof of the mouth, and twisting its pedicle round, so that the 
flap may be adapted by means of suture to the loss of substance in the 
palate." 

I must refer my readers to the different writers on surgery for the 
various attempts which have been made to remedy this defect by the 
substitution of an artificial palate. If it be necessary at all, it is at 
least desirable to wait until after the age of puberty, and therefore the 
subject hardly comes within the scope of a treatise on diseases of chil- 
dren. 

589. Imperforate Anus. — In this malformation the lower portion 
of the intestine terminates in different ways, which materially affect the 
operation for its relief and the results. 1. The anus may be closed by 
a thin membrane, the rectum being perfect ; in such cases the membrane 
generally projects, the blue color of the meconium is discernible, and 
there is a feeling of fluctuation or something very like it to the touch. 
2. The rectum may terminate an inch or so above the anus, and there 
will then be no projection, the skin will retain its natural color, and the 
parts will feel firm and solid. 3. Sometimes the intestine does not de- 
scend lower than the upper part of the sacrum. " Dr. Palmer dis- 
sected a case where the colon, after reaching the vicinity of the left 
kidney, began, as it descended, to form a sigmoid flexure, but, previ- 
ously to its arrival at the concavity of the left ilium, made a sudden 
turn to the right, and crossing the psoas muscle, reached the projec- 
tion of the sacrum, where it terminated without entering the sacrum at 
all. With this malformation was combined an imperforate meatus uri- 
narius and other considerable deviations of the genital organs from the 
natural structure." 2 4. Occasionally the colon terminates in a cul de 
sac, the rectum being entirely wanting. 5. Although the anus may be 
perfect, yet if there be a closure of the rectum by membrane higher up, 
as sometimes happens, the result will be the same. 6. In any of these 
cases there may be an attempt to afford relief naturally by an opening 

1 London Journal of Medicine, No. 2, p. 117. 

2 Med.-Chir. Journal, 1816, vol. i. 



414 CONGENITAL MALFORMATIONS. 

into the bladder, as in a case lately under my care, or into the urethra, 
in the male, or vagina in the female. 

In a fatal case lately under the care of Dr. Sawyer, of this city, and 
of -which he has made a careful dissection, he found that the rectum 
opened into the urethra, anterior to the membranous portion. 

590. We can easily understand that this malformation must speedily 
be attended with very serious or fatal consequences. If relief be not 
afforded, the infant perishes with symptoms of strangulated hernia. 

Mr. A. C. Hutchinson recommends that the operation should be de- 
ferred until from twenty-four to sixty hours after birth, the advantage 
being, that the intestine being distended by the meconium, will be a 
guide to the operator in making an incision. 

At all events, within a moderate time after birth, an attempt must be 
made to afford relief by evacuating the contents of the intestine. 

591. When the anus is merely closed by a membrane projected down- 
wards by the meconium, whose color is discernible, the operation is sim- 
ple, and consists in making a crucial incision through the centre of the 
prominence and removing the corners. After the rectum is emptied the 
wound must be kept open by a portion of a bougie, elastic gum catheter, 
or, what I found answer equally well, a small glyster-pipe. It is little 
matter what means are used, if the end be attained. 

592. But when no external appearance denotes where the anus ought 
to be, and when the touch gives us no information, the case is much 
more difficult, inasmuch as we know not how far distant the intestine 
may be from the surface, and consequently are ignorant how far we 
may have to penetrate before relief be afforded. " However," as Mr. 
Cooper observes, " it is the surgeon's duty to do everything in his 
power to afford relief. For this purpose, an incision an inch long, or 
rather more, is to be made in the situation where the anus ought to be, 
and the wound is to be carried more and more deeply in the natural 
direction of the rectum. The cuts are not to be made directly upwards, 
nor in the axis of the pelvis, for the vagina or bladder might thus be 
wounded. On the contrary, the operator should cut backwards along 
the centre of the concavity of the os coccygis, where there is no dan- 
ger of wounding any part of importance. In all cases of this kind 
the surgeon's finger is the best director. The operator, guided by the 
index finger of his left hand, introduced within the os coccygis, is to 
dissect in the direction above recommended, until he reaches the feces, 
or has cut as far as he can safely reach with his finger. If he should 
fail in finding the meconium, as death must unavoidably follow, one more 
attempt ought to be made by introducing upon the finger a middle- 
sized trocar in the direction, but calculated to reach the rectum, with- 
out danger to other parts, viz : upwards and backwards in the median 
line. The canula may be left in the puncture, and secured there with 
tapes, so as to afford an outlet for the feces. In some observations on 
this subject, addressed to the Medical and Chirurgical Society by Mr. 
A. Copland Hutchinson, he recommends an elastic gum catheter to be 
substituted for the canula, after a week ; and when the tube can be dis- 
pensed with, a sponge tent, or a piece of bougie, to be worn twelve out 
of the twenty-four hours." 



IMPERFORATE ANUS. 415 

M. Wolff, after cutting to the depth of two inches without finding 
the gut, was enabled to reach it by means of a pharyngotomus, and the 
child recovered. 

The great difficulty appears to be to prevent the wound closing. Mr. 
Bell states that it was only by most assiduous attention for eight or ten 
months that he obviated the necessity for another operation. Mr. Mil- 
ler, of New Haven, had to repeat the operation ten times before the 
child was eight months old. In the case under my care I had to repeat 
the operation once, and by great care it has perfectly recovered. A 
portion of a catheter, or bougie, a short glyster-pipe, or, in short, any 
matter which can be maintained in the wound, and which reaches into 
the intestine, will answer the purpose. 

593. If the obstacle should be high up, the anus being perforate, we 
must endeavor to ascertain its nature and extent ; if it can be relieved 
by dilatation well and good, if not it must be divided either with a blunt- 
pointed bistoury or a pharyngotomus, and the opening maintained by a 
bougie. 

When, in addition to an imperfect or imperforate anus, there is an 
opening into the bladder, vagina, or urethra, the best remedy for the 
latter is making the former more free ; the more feces pass through the 
anus the less will escape by the supplementary passage ; it is rarely 
necessary to do more. In my case the feces passed by the urethra 
before and a few days after the operation ; but as the one passage 
became more free, the other ceased to be used altogether. 

The attempts to remedy this formidable defect do not appear to have 
been as successful as we might have hoped ; by far the larger number 
of children die after the operation, but how far the operation has a share 
in the mortality it would be difficult to say. A small number recover, 
and I am inclined to think that those upon whom the operation is per- 
formed with the least delay have the best chance. The little boy upon 
whom I operated is now seven or eight years old and healthy. A 'case 
of recovery is related recently by Dr. Thompson, of Tennessee. 1 

594. But suppose that we cannot reach the intestine in the way 
already pointed out, and that we must conclude that there is some ex- 
traordinary malformation, as in Dr. Palmer's case, what is to be done ? 
If we do nothing the child's death is certain, therefore some risk may 
very properly be incurred. 

In 1720 M. Litere proposed to make an artificial anus by opening 
into the sigmoid flexure of the colon, above the left groin. M. Dumas 
tried this plan in 1788, but the infant died. In 1793 it was practised 
with complete success by M. Duret, of Brest, and M. Pilore, of Rouen. 
Dessault, Ouvrard, and Roux, lost the cases in which they tried it. 2 

" The operation consists in making an incision a little above Pou- 
part's ligament, about two inches in length, and on the outer side of 
the curve of the epigastric artery : the skin, superficial fascia, aponeu- 
rosis of the external oblique muscle, the lower fibres of the internal 
oblique and transverse muscles, the fascia transversalis, and the peri- 

1 Philada. Med. and Surg. Journal, Aug. 15, 1853, p. 81. 
3 Velpeau, Nouv. Elem. de Med. Operat., vol. iii. p. 983. 



416 DENTITION. 

toneum, are to be divided in succession. As soon as the peritoneum 
has had a small puncture cautiously made in it, a director is to be in- 
troduced into the opening, which is to be enlarged with a probe-pointed 
bistoury. The distended bowel, of a livid or greenish color, presents 
itself in the wound, and, being opened in the same direction as the 
wound, a tent or piece of full-sized elastic gum catheter should be placed 
in the new passage. The introduction of a ligature through the mesen- 
tery is sometimes advised, but as my observations apply only to open- 
ing the sigmoid flexure of the colon, such expedient is out of the 
question." 1 

Though we may be justified in having recourse to the operation as a 
dernier ressort, the results do not seem to afford much hope of success. 



CHAPTER II. 



DENTITION. 



595. Before we proceed to examine into the consequences of severe 
dentition, it may be as well to lay before the reader the ordinary course 
of dental development, in which medical interference is rarely necessary. 

Meckel, Sims, and others, agree that the formation of the teeth com- 
mences at a very early period of embryonic life, by an ossific deposit 
upon the pulp, which is extended and developed from without inwards, 
so that the grinding surface and shell of the tooth are first formed, with 
a central cavity, which gradually diminishes as the osseous matter in- 
creases, to form the body : last of all the roots are formed. The teeth 
are inclosed in a capsule consisting of two lamellae, from the union of 
which the pulp is developed: and the entire, at birth, are inclosed in 
and covered by a considerable thickness of gum. 

" The membrane which secretes the enamel invests the course of the 
tooth, and adheres firmly to its neck. As ossification advances, the 
crown of the tooth rises, and the membrane of course accompanies it. 
On the tubercles and cutting edge of the tooth the crystallization of the 
enamel is first completed, and the process continues until the neck is 
reached ; the membrane covering it, becoming gradually thinner and 
less vascular, is at last quite absorbed. The absorptive process goes on 
in the gum covering the tooth, which at last presses through, and is said 
to have cut the gum." 2 

596. The period of the first dentition is subject to some variation, 
but as a general rule we may say that it occupies from the seventh 
month to the twentieth or thirtieth. The teeth commonly appear in 
each jaw in couples ; thus about the seventh month we find the two 
central incisors of the lower jaw appear; then, after a short time, those 

1 Cooper's Surgical Dictionary, p. 211. 

2 Askburner on Dentition, p. '69. 



DENTITION. 417 

of the upper jaw, followed after an interval by the lower lateral incisors, 
and then by the upper lateral incisors. From the twelfth to the four- 
teenth month the four first molar teeth appear, and from the sixteenth^ 
to the twentieth the lower and upper canine teeth; last of all the four 
last molars. The succession here stated has been observed by Serres 
and De la Barre to be the general order in which the teeth become 
ossified, and Dr. Ashburner's experience agrees with theirs. 

The lower incisors generally appear first, and Dr. M'Clintock has 
suggested that in this order there is a beautiful provision for the pro- 
tection of the mother. The tongue of the child protects the nipple from 
irritation by the lower teeth when sucking, but it cannot from the upper ; 
if, therefore, the upper teeth appeared first, the nipple would be exposed 
to injury from which, for a considerable time at least, it is now guarded. 

M. Trousseau states the succession thus : 1. The two inferior median 
incisors. 2. The four superior incisors. 3. The inferior lateral incisors, 
and the first four molars. 4. The canine, and 5. The last four molars. 

But although this sketch may indicate sufficiently well the usual 
process of teething, it is a rule to which there are many exceptions, a 
law from which there are many deviations. Children are occasionally 
born with teeth, or cut them shortly after birth. I knew a child who 
was found to have three well-developed teeth at birth, and others who 
cut two and four the first fortnight of their life. Dr. M'Clintock saw 
one child, at the Hospital, born with the two middle upper incisors cut. 
Haller has noted nineteen cases of the precocious appearance of the first 
teeth. Denman mentions a child born with teeth, and Ashburner one 
of a child who cut the two incisor teeth of the lower jaw before three 
months old. Louis XIV. of France, B-ichard III. of England, and 
Mirabeau, were said to have been born with teeth. 

Neither do they always appear in pairs. I have a little patient in 
whom the right lateral incisor of the upper jaw did not make its ap- 
pearance before three years old, although she possessed all the other 
incisors, canine teeth, and some of the molars. Occasionally, the late- 
ral incisors appear before the central ones, or the canine teeth before 
the incisors. 

On the other hand there is often great delay before the teeth appear. 
Van Swieten mentions a healthy child that did not cut a tooth until 
it was nineteen months old ; Underwood one at twenty-two months ; 
Dumas one beyond seventeen months ; and Serres quotes a case from 
Lanzoni of a little boy who did not cut his first teeth until he was seven 
years old. Dr. Ashburner saw " a child twenty-two months old be- 
ginning to cut its first tooth, which was an incisor in the upper jaw." 
Fouchard gives an instance in which, at six years old, the child had but 
the front teeth, and Rayer one in which the four canine teeth did not 
appear till thirteen years of age. 

Very frequently, this order of succession is violated; the upper inci- 
sors may appear before the lower, the molars before the canine teeth, 
or even before the lateral incisors, and perhaps all the upper teeth 
taking precedence of the lower. Dr. Hamilton observes : " In some 
rare cases, the grinders come out before the cutting teeth, and the usual 
order of succession is changed. It is not uncommon, too, for several 



418 DENTITION. 

pairs to succeed each other rapidly, and then for a considerable period 
to elapse before the rest advance. In general, the later the commence- 
ment of teething the shorter are the intervals between the several 
pairs." 1 

For further examples of abnormal variations in teething, I must refer 
the reader to Meckel's Anatomy, and to the special works on the 
teeth. 

597. Let us now consider the second dentition, 
second set of teeth," says Dr. Ashburner, in his excellent little 
" have long existed in the jaws. It has been remarked that the germs 
of the first dentition are attached, in the foetus, immediately to the 
membranous folds which at this period constitute the gums ; and that 
those of the second dentition are suspended from them by means of 
small pedicles. When the capsules of the first dentition were advancing 
towards their development, and were approaching the upper part of the 
gum, those of the second appeared to retreat into the depths of the jaw, 
and hung to the gums by their pedicles. The pedicle in the process of 
growth is destined to perform an important part. It becomes a fibrous 
canal, communicating between the alveolar margin and the cell in 
which the capsule is lodged. It is apparently periosteum ; but, what- 
ever may be its real nature, it leads to the tooth, and becomes continu- 
ous with the external layer of the dental membrane." " The gums 
grow, they enlarge ; as their volume increases, the germs of the per- 
manent teeth continue to develop the organs they have to form. These 
germs are inclosed in cells in the bony substance of the jaws. Up to 
the age of five, six, or seven years, the jaws of a child may be said to 
contain two sets of sockets," 2 which are kept distinct by a bony lamina. 

But whilst this process of growth and development of the jaw and 
second set of teeth is going on another commences, having reference to 
the first set. The root is gradually absorbed, so that if we remove a 
loose primary incisor, we shall find it more or less deprived of root, 
according to the time absorption has been going on, and apparently 
seated on the gum rather than inserted into it. When the absorption 
is far advanced, the tooth becomes dead and loose, and when completed 
it falls out or is removed by the child itself. Previous, however, to the 
decadence of the first incisors, we generally find a molar tooth of the 
permanent set make its appearance behind the last molar of the first 
set, the jaw having expanded so as to afford sufficient space. The age 
at which these first appear is stated differently; by Soemmering at seven 
or eight years ; by De la Barre at five or six ; by Bell at six and a 
half, and by Ashburner at about six years, although he saw them cut 
through in one case at three and a half years. The incisors are some- 
times shed before the molars appear. 

This condition, of course, increases the total number of teeth. The 
first set consists of twenty, and then four permanent molars make the 
number twenty-four. 

Soon after the appearance of these molars (or sometimes before), at 
the age of five, six, or seven years, I have said that the central incisors 

1 Diseases of Infants, p. 73. 2 On Dentition, p. 62. 



DENTITION. 419 

loosen and fall out ; and, the same process of absorption extending to 
the roots of the other deciduous teeth, they are likewise shed success- 
ively, and, as a rule, pretty much in the order in which they appeared, 
but with uncertain and considerable intervals between each pair. The 
temporary incisor and canine teeth are thus replaced by permanent 
incisor and canine teeth, and the four deciduous molars in each jaw 
(two on each side) by four bicuspid teeth, making twenty-four, which, 
with eight more (four molar and four wise teeth), make the full set of 
thirty-two. 

Now " let us inquire into the epochs for the appearance of all these 
teeth. We have seen that the two deciduous central incisors of the 
lower jaw, belonging to the first set, fall away about the age of seven 
years. The vacant spaces are soon to be occupied by a couple of incisor 
teeth, which cut through the gums with edges that are serrated — an ap- 
pearance that time takes away. When these teeth are half up, the two 
superior central incisors fall away, and are succeeded by two much 
larger teeth. In consequence of the want of a perfectly normal instance 
of healthy growth, it is very difficult in London to fix the time when the 
next two incisors, the lateral of the lower jaw, should fall out. Irregu- 
larities in this respect are very numerous, for the perfect consent be- 
tween the growth of the teeth and that of the jaws is wanting. The 
common occurrence is that of a pressure, from deficient growth of the 
jaw, turning the newly arrived central incisors out of their line for a 
time, producing an angle at the median line instead of a continuous arc ; 
and their backs appear to be pushed towards each other. In most cases, 
the jaw increases in time, and the teeth assume their proper stations. 
About a year is occupied in shedding the four central incisors, and ano- 
ther year in that of the four lateral incisors. The anterior bicuspid 
teeth of the lower, then those of the upper jaw, are next to be shed. 
These occupy another year. The posterior bicuspids go next, and then 
comes the turn of the cuspidati or canine teeth ; but very often the 
canine teeth take precedence of the posterior bicuspid. The falling out 
of the posterior deciduous molars and canine, and replacing by these 
teeth, is a process that lasts from about nine and a half till twelve. In 
the mean time, the jaws manifestly enlarge, particularly at the posterior 
part. Spaces are found behind the first permanent molars. These 
teeth appeared at six years of age, and before thirteen and a half four 
new molars are cut. 

" The individual has now completed the development of twenty-eight 
teeth, and is nearly ready to encounter the further unfolding of the 
frame which is implied by the changes attendant on puberty. Three or 
four years seem to be required for a due perfection in the growth of the 
organs of reproduction ; and during the remainder of this septenary 
period the system adds accretion to the body, while four new molar 
teeth are put forth, completing the full number of thirty-two teeth in 
the mouth. These last four, cut between seventeen and twenty-one 
years of age, are the wise teeth, or dentes sapientiae." 

Deviations from the ordinary rule are just as common with the second 
dentition as with the first, and all we can attempt is an approximative 
estimate. 



420 DENTITION. 

598. From what has been said, it will be perceived that the resist- 
ance to the first set of teeth arises first from the fibrous capsule, and 
secondly from the gum, which is tolerably thick over the teeth, and of 
a dense texture. Through these structures the tooth must force its way 
by pressure, and consequent absorption, as it ascends. As the tooth 
rises, the anterior and posterior walls^ of the gum appear to separate, 
and the edge spreads out and becomes broad; the gum swells, its texture 
is less dense and more vascular, and it rises on either side the central 
line or ridge until this appears rather as a depression. As absorption 
proceeds, the gum immediately over the tooth becomes thinner and 
paler, until we can distinctly trace the edge of the tooth through it. 
At length the gum is pierced and slightly retracted, and the tooth is 
said to be cut. Occasionally, I have noticed a drop of straw-colored 
fluid between the tooth and the surface of the gum, giving it the ap- 
pearance of a vesicle. 

The second dentition gives much less trouble, and for obvious reasons. 
The teeth which supply the place of the first set have little more than 
the resistance of their own capsules to overcome. The vacancy left by 
the first is merely healed over, and easily opened by the second, which 
so soon succeed. The additional molar and wisdom teeth, of course, 
meet with as much or more resistance than the first set. 

599. If the child be healthy and the process of dentition favorable, 
the suifering is not great, and the distress is almost entirely local. For 
some time before, the gums are much swollen ; there is an abundant 
flow of saliva from the mouth; the child dribbles, as it is called, inces- 
santly, and thrusts its finger, or anything it can seize, into its mouth ; 
and if we put our finger into its mouth, instead of sucking as hereto- 
fore, it attempts to relieve the irritation of the gums by biting. Up to 
this time, the mouth is quite cool. As the teeth advance in the gums, 
the latter swell and become softer and tender, but with a feeling of 
tension and itching, which makes the infant anxious to close them upon 
something, or to press something against them, even though this be ac- 
companied with some degree of soreness. There are occasional stings 
of pain, as we know by the sudden cry of the child ; and if there be 
several teeth coming forward, or if the gums appear inflamed, the mouth 
will feel hot to the finger. The child now bites vigorously; its mother 
does not escape with impunity, and it carries everything it can seize to 
its mouth. It is fretful and uneasy, does not sleep as quietly as usual, 
and the bowels may be rather more free than at other times. The drib- 
bling continues until the tooth is cut through. The irritation may ex- 
tend to the lining membrane of the nose, or to its nerves, and the child 
be observed to sneeze frequently and to rub its nose. 

It would seem that dentition is commonly more severe in the winter 
than in the summer, and certainly more so in large cities than in the 
country; and its consequences are more serious in badly nurtured child- 
ren of delicate constitution, and among the poor. 

This, I think, is a pretty accurate description of a case of easy den- 
tition, in which the local distress is not excessive, and there is neither 
fever nor sympathetic irritation. So long as this is the case, inter- 
ference is unnecessary; there is no reason for lancing the gums, and 



DENTITION. 421 

the slight diarrhoea is beneficial. Ivory, caoutchouc, or gutta percha 
rings, for the child to bite, are useful. Davies prefers a flat ivory ring ; 
but, in my opinion, by far the best thing is a finger-shaped crust of bread, 
or a biscuit, if care be taken that the infant do not break or bite off a 
piece. 

600. Now let us turn to the cases of severe dentition, in which we 
find the local symptoms considerably aggravated. The mouth is hot, 
and in some cases dry ; the gums are of a bright or deep red color, much 
swollen, and very tender. The child is not now inclined to bite, on ac- 
count of their tenderness, and in some cases even sucking gives pain. 

The suffering is very considerable ; the child is restless, cross, and 
uneasy, crying bitterly without any cause, and refusing to be comforted 
and amused by its usual playthings. Its sleep is disturbed ; sometimes 
it cannot settle to sleep, at others, after sleeping for a while, it awakes 
up crying. Its thirst is great, and it takes cold drinks with avidity. 
The flow of saliva may be nearly arrested, or it may be excessive, and 
occasionally the submaxillary glands are enlarged and tender. The 
cheeks are flushed, especially after sleep. 

If the local inflammation continue to increase, we may find the ap- 
pearance of muguet on the inside of the lips or cheek, or the gums may 
ulcerate. 

The local treatment is simple enough. The distress results from 
inflammation of the gums, excited and kept up by the pressure of the 
teeth, and it will be almost instantly relieved by dividing the gums 
freely with a gum lancet. 

601. There are one or two points, as regards lancing the gums, 
which I should wish to impress upon my junior readers. First, that, 
in order to perform the operation effectually, the gum lancet should 
have a back spring like a knife, and not an open back like a bistoury ; 
for it is almost impossible to lay open the gums thoroughly with an 
instrument that is not firm and steady, and still less with a common 
lancet, although that has been recommended. 

Secondly, that a slight scarification of the gums for the relief of 
teething is of no use whatever ; they must be cut down until we feel 
the lancet touch the tooth, and to the full extent of the swollen gum 
and a little further. I have often seen the irritation continue as severe 
as ever after an incision over the central incisors, because the operator 
had not noticed that the lateral ones were pressing forward, and so of 
the other teeth. 

Moreover, when the suffering is very great, or in the case of the 
molars, or with the canine teeth, which commonly make their appear- 
ance between the lateral incisors and first molars, it is quite necessary 
to make a crucial incision down to the tooth, so as to free it com- 
pletely. 

And I would beg to impress on the student that, owing to the fright 
of the mother or nurse, and the cries and resistance of the child, to 
lance the gums effectually is by no means an easy operation, but one 
that requires both firmness and deliberation to avoid, on the one hand, 
cutting too superficially or too limitedly, and, on the other, wounding 
the mouth or tongue. 



422 DENTITION. 

Lastly, in severe cases the operation will have to be repeated. It is 
a very good plan when the sympathetic irritations (of which I shall 
speak presently) do not speedily subside, to run the lancet along the 
old incisions every three or four days ; it gives no pain, and prevents 
the wound from closing over. 

It is a mistake to suppose that the gum when healed is more resisting 
to the tooth than if it had not been lanced, unless a very long time 
have elapsed ; and it is to be presumed that ordinarily no such early 
lancing will be necessary, but when it is so the gum must of course be 
reopened. The repetition may be necessary, either because the gum 
has healed, or because the first operation was ineffectual, or as a pre- 
caution if the sympathetic irritation continue. In very severe cases, 
when the ordinary lancing does not seem to afford adequate relief, we 
have been advised to shave off the entire edge of the gum over the tooth 
with a bistoury. I have never found this necessary, but I had a case 
lately in which I was obliged to use the lancet thirty or forty times, 
each tooth requiring several operations, and the suffering continuing 
until all were cut. From this case, and some others like it, I am 
inclined to believe that there is an irritation of growth as well as that 
arising from the resistance of the gum, for the latter I took care to 
remove or prevent. In very rare cases the bleeding from the wound 
has been excessive, but it may be arrested by pressure, astringents, or 
caustics. 

602. Besides lancing the gums freely, it is desirable that the bowels 
should be more free than at ordinary times, and even if they are some- 
what purged it will not signify, as this is by far the safest local irrita- 
tion a child can experience during dentition. If, however, they should 
be too much moved, and with griping pain, we may easily moderate by 
chalk mixture with aromatic confection, and a drop or two of laudanum 
to the ounce, according to the age of the child, taking care only to 
moderate and not to arrest the action of the bowels. 

If the gums are disposed to ulcerate it will be well to apply a little 
borax and honey to them occasionally, or a little acid and water ; but 
in general they are so much relieved by the lancing that they recover 
their healthy state without any application. 

603. But the suffering occasioned by dentition is not confined to the 
mouth ; if it exceed a certain amount, or in children of an irritable 
constitution, the irritation is reflected by the nervous system to some 
other organ or system of organs. The sympathetic irritations occur 
pretty much in the following order. 

I. The most common disturbance is irritation of the bowels, as I 
have already mentioned, diarrhoea, with griping pain, and sometimes 
tenesmus. If it be not excessive it seems rather a relief, and as it is the 
least injurious of all the irritations resulting from dentition, we should 
rather moderate than altogether arrest it. The child will certainly 
become weaker, thinner, and its flesh soft and flabby, but this will 
rapidly be remedied when the teeth are through. 

When it is excessive, and the quantity and frequency of the discharge 
are great, we shall find it necessary to interfere with a mixture of chalk 
and laudanum, as just recommended, increasing the laudanum if neces- 



DENTITION. 423 

sary, or adding tincture of kino or catechu. If there be much pain 
and flatulence, an occasional warm bath and the use of a liniment com- 
posed of half a drachm of laudanum to two ounces of compound cam- 
phor liniment, will be found of great service. If this fail, a mustard 
and linseed-meal poultice (one-third of the former to two-thirds of the 
latter), or a blister to the epigastrium for an hour or two, may answer 
the purpose. 

Vomiting does not always coexist with the diarrhoea of dentition, but 
it does sometimes, and may prove very troublesome, especially because 
it deprives the patient of food, and renders the administration of reme- 
dies difficult, so long as it continues. As a general rule, it is the con- 
sequence of irritation, and not of inflammation, and will be relieved 
by the division of the gums, and the exhibition of half a drop or a drop 
of laudanum, or counter-irritation to the epigastrium. 

M. Cruveilhier has described an affection, apparently caused by den- 
tition, under the title " Maladie gastro-intestinale des enfans avec des- 
organization gelatiniforme," in which thirst, vomiting, and purging, 
with collapse, are the leading symptoms. This disease, however, is so 
much more serious than the ordinary vomiting and purging of dentition, 
as to deserve a distinct notice; and the same may be said of the disorder 
noticed by M. Guersent. 

In all these affections of the digestive tube, warm baths, emollient fo- 
mentations, poultices, and slight counter-irritants to the abdomen, are 
exceedingly useful ; but we must also regulate the diet carefully. If 
possible, the child should have its natural food, and but little besides, if 
it agree with him ; but if it be already weaned, the diet should be of the 
simplest kind — boiled milk or milk and water, rice milk, thin arrow- 
root made with milk, bread jelly, &c. 

604. II. Next to the stomach and intestinal canal, and often coinci- 
dent, the most frequent seat of irritation is the skin. Patches of papu- 
lar eruption appear on different parts of the body, particularly the face 
and disappear after a time ; or the child may be attacked by some more 
permanent eruption, such as crusta lactea, prurigo, eczema, &c, espe- 
cially of the scalp, which, while it affords relief for the time, becomes 
itself a very troublesome disease, requiring special treatment, and 
which, unlike many other irritations, is not necessarily cured by the 
liberation of the teeth. If any disease of the skin should exist previous 
to dentition, it will be found much more difficult, if not impossible, 
to cure it, until that process is completed. Even when apparently cured, 
the irritation of teething will cause the eruption to reappear. The 
relief of the gums is then an essential part of the treatment of the 
cutaneous affection. 

We often find that during dentition the parts behind the ears be- 
come soft, tender, and inflamed, with a discharge which keeps these 
parts excoriated and sore. Among the poor this is regarded as a mat- 
ter of course, and little or no efforts are made to cure it until after the 
teeth are through ; but if we relieve the gums, the ears may be also 
restored to their natural condition by a little black wash and gentle 
purgatives. As it is a natural derivation, it might be unwise to stop it 
unless other means were adopted for the relief of the original irritation. 



424 DENTITION. 

605. in. Probably the next sympathetic irritation, in point of fre- 
quency, is some irritation of the nervous system. This may develop 
itself in different localities, and with different degrees of intensity. 

I saw the other day a single attack of spasm of the glottis, resulting 
from teething, and relieved by lancing the gums. 

Or the spasm may return frequently in the course of the day, and 
continue for weeks, alternating with convulsions. 

Lancing the gums is absolutely necessary, and generally relieves the 
child, but as the attack is apt to return with each tooth, further measures 
must be adopted. The bowels should be kept rather more free than 
usual, warm baths given occasionally, the gums freely divided at the 
first sign of dental irritation, and if necessary, a blister applied behind 
the ear, or to the back of the neck, or if more permanent counter-irri- 
tation be desired, a seton of three threads of silk inserted into the arm. 
Fresh air is very desirable, and if possible, a change of air from the town 
to the country. For further details I must refer my readers to the 
chapter on spasm of the glottis. 

But, instead of spasm of the glottis, the child may have a fit of con- 
vulsions, partial or general, limited to the muscles of the face or one 
extremity, or involving the whole body. The symptoms and treatment 
have already been described ; the most important point to remember is, 
that although dentition may be the sole cause, lancing the gums, warm 
bath, and purgatives may not be all that is necessary for the cure, but 
we may be obliged to have recourse to bloodletting or leeching, with 
subsequent counter-irritation. 

Lastly, the distress of teething may give rise to paralysis of an arm 
or a leg or both together, or of the muscles of one side of the face. It 
may occur with the first dentition; but asDr.Fliess has observed, it is more 
common during the second. It is remarkable for the suddenness of its 
attacks ; the child may appear quite well the previous day, but during 
the night it is uneasy and restless, grinds its teeth and screams or 
groans. There may be some thirst, a degree of heat about the head, 
and feverishness. The next morning it is found to have lost the power 
of an arm or leg, or in rare cases of both : the limb is warm but hangs 
powerless, and from the gravitation of the blood is of a darker color 
than the other. Sensibility is either much diminished or altogether 
lost : the child rarely complains of pain, but sometimes of a sense of 
dragging from the shoulder. 

When one side of the face is affected, the distortion will attract im- 
mediate attention, the mouth is drawn to one side whenever the child 
attempts to speak or is excited, and the greater the excitement, the 
more marked the distortion. When perfectly, quiet, the face in most 
cases appears quite natural. 

The attack does not often prove fatal ; if the teeth be cut through 
naturally or liberated by the lancet, the paralysis may gradually wear 
off and the child recover the use of the limb or face, or the paralysis 
may become chronic, without any very obvious disease of the nervous 
system, the limb remaining powerless or nearly so, and gradually be- 
coming atrophied, or the distortion of the face continuing during life. 

Lastly, when the paralysis resists all treatment, we find symptoms 



DENTITION. 425 

gradually developed which indicate disease of the spinal cord and brain. 
The child is attacked with dyspnoea, palpitations, twitching of the eyes, 
squinting, and at length becomes comatose and dies. 

We have seldom an opportunity of ascertaining the state of the spinal 
marrow by a post-mortem examination, but in one case of the kind, who 
was killed suddenly, Dr. Fliess found a remarkable degree of vascu- 
larity about the roots of the brachial nerves, the membranes were 
reddened and the whole circumference seemed congested, 1 but there 
was no real organic change. It is clear, therefore, that this is a disease 
of reflex irritation. 

The proper treatment consists in relieving the irritation of the gums, 
in the first instance by a very free scarification, and if necessary by the 
removal of the primary teeth, then by cupping or leeches to lessen the 
vascular congestion about the roots of the nerves. The limb may be 
wrapped in flannel, and mild purgatives given. The application of 
stimulants or electricity to the affected limb is of no benefit at first ; 
when the disease has become chronic they may be worth trying. 

606. IV. Affections of the chest, bronchitis, pneumonia, &c, are 
often attributed to the irritation of teething ; and without calling in 
question the possibility, I am inclined to think that in many of these 
cases it is merely a coincidence. The child takes cold when teething, 
and as undoubtedly it will be difficult to cure the pulmonary affection 
until the gums are relieved ; the two are connected as cause and 
effect. In addition to the proper remedies for the disease, we should 
always lay open the gums, whenever we have reason to suspect the 
slightest irritation from the teeth. 

607. Many other diseases are enumerated as resulting from dentition, 
but those I have named are the principal ones. The list has, no doubt, 
been lengthened by including coincident affections arising from other 
causes, just as the mortality attributed to dentition embraces many 
cases in which death resulted from the secondary or synchronous dis- 
order. At the same time I differ from those who go to the opposite 
extreme, and deny all secondary diseases, and nearly all fatality arising 
from dentition. 

Formerly it was extremely difficult to comprehend the mode in which 
the secondary affections occur ; but since Dr. Marshall Hall's brilliant 
discovery of the reflex action of the nerves, we understand so far that 
the irritation of the gums, conveyed to the nervous centres, is thence 
reflected, or rather projected to some other organ ; but of the laws 
which determine the particular organ or system thus affected we know 
as yet but little. 

In conclusion, I would beg my junior readers to bear in mind that 
many diseases which prove obstinate in infancy and childhood, but 
which originated quite independent of dentition, may owe their persist- 
ence to an access of teething arising during their course, and that we 
shall fail in curing them unless we first relieve the gums. In fact, the 
diseases which are easily cured at other times, become excessively obsti- 

1 Journal fiir Kinderkrankueiten, June and July, 1849. Lond. Journ. of Med,, Jan. 
1850. 



426 STOMATITIS. 

nate during dentition, and it will be well always to ascertain the state 
of the teeth whenever we find such diseases do not yield to our treat- 
ment. This applies equally to most of the diseases of infancy, and 
especially to diseases of the skin, during both the first and second den- 
tition. 

With the exception of diseases of the skin and the bowels, the second 
dentition rarely excites any sympathetic affection, nor is the local irri- 
tation great. The posterior molars and the wisdom teeth give a good 
deal of pain, which may be relieved by a touch with the lancet. 



CHAPTER III. 

INFLAMMATION OF THE MOUTH. — ERYTHEMATOUS STOMATITIS. 

608. Inflammation of the mouth is sufficiently common among 
children of all ages, from birth to ten or twelve years old, and we find 
it varying in extent and intensity, constituting the simple or erythe- 
matous stomatitis, muguet or pseudo-membranous stomatitis, aphthae or 
ulcerated stomatitis, and gangrene or cancrum oris, described by authors. 

In simple or erythematous stomatitis, the mucous membrane is ob- 
served to be unusuall} 7 - red, either generally, in points, or in patches. 
The entire surface of the mouth may be involved, or only the mucous 
membrane lining the cheek, or merely the gums, and in the latter case 
we find them spongy, with their edges rounded, swollen, and somewhat 
loosened from the teeth. The mucous membrane thus affected, is, as I 
have said, of a deeper or brighter color than usual, puffy, and extremely 
tender to the touch. The mouth is very hot, and, except at the begin- 
ning, there is a profuse secretion of a colorless bland saliva. 

The child is extremely uneasy, restless and fretful, and, when suck- 
ing or eating, is evidently in great pain. 

In addition to these local symptoms, in many cases we shall find the 
bowels disordered, with flatulence and griping. 

Very little fever accompanies this affection, except in those cases 
where the child is, in addition, suffering from dentition. 

609. Causes. — The causes to which the disease may generally be 
attributed are either a disordered condition of the intestinal canal, or 
dentition. Both give rise to irritation at the commencement of the 
digestive tube ; and in the latter case, if the patient have already teeth 
in one jaw, their pressure upon the opposite gum, already swollen by 
the teeth approaching the surface, very frequently converts irritation 
into positive inflammation and slight ulceration, which may spread to 
the neighboring parts. Any irritating matters taken into the mouth 
may give rise to stomatitis, and it not unfrequently occurs in the course 
of certain eruptive fevers, as measles and scarlatina. 

610. Treatment. — In its simple form, the disease involves no danger, 
and is easy of cure. The bowels should be freed by a brisk purgative, 



MUGUET. 427 

if they be at all confined ; but if there be irritation and diarrhoea, we 
shall clo better to quiet that before clearing the intestinal canal. 

If the child be teething, the gums must be freely lanced, and, these 
sources of irritation being removed, very simple local treatment will be 
sufficient. 

Cool emollient drinks, which the child will eagerly take, are the best 
application in the acute stage ; and when this is past, we may gently 
apply a little honey, then a little borax and honey, in such proportions 
as the patient can bear. If this fail, we may try a mixture of honey, 
alum, and water, in the proportion of one part of alum to fifteen of 
honey, and seven of water, as recommended by M. Bouchut. But the 
great point is to restore the stomach and bowels to their healthy con- 
dition. 

Generally speaking, the attack subsides easily, but if neglected or 
badly treated, or if more than usually severe, it may give rise to 
muguet, aphthae, or ulceration. 



CHAPTER IV. 

MUGUET.— PSEUDO-MEMBRANOUS STOMATITIS. 

611. This common affection of infancy and childhood has long been 
known to practitioners under various names, as aphtha lactantium, 
aphtha lactamen, aphtha infantilis, although its true nature and seat is 
a modern discovery, due chiefly to the labors of Guersent, 1 Lelut, 2 
Billard, 3 Valleix, 4 &c. 

By many it has been and still is confounded with the vesicular aphtha, 
or thrush, though no two diseases can be more distinct, muguet being 
an abnormal secretion upon the mucous membrane of the mouth, and 
thrush consisting of a vesicle or pustule formed beneath the epithelium. 

Muguet may be either idiopathic or symptomatic, either a primary or 
a secondary affection. 

612. Symptoms. — After inflammation of the mouth has continued for 
a longer or shorter time without yielding to treatment, or without our 
being aware of any previous inflammation, we may observe in different 
parts of the mouth small points or patches of a curdy matter, at first, if 
the child be sucking, probably mistaken for the remains of milk. This 
matter, however, is adherent to the subjacent membrane, although by a 
little trouble it may be removed. 

These points or patches sometimes disappear in a few hours, if the 
attack be very slight; but if severe they increase and coalesce, so as to 

1 Diet. deMed., art. Muguet, Stomatite. 

2 Arch. Gen. de M6d., vol. xiii. p. 335, 1827. 

3 Traite des Mai. des Enfans, p. 199. 

4 Cliuique des Mai, des Eufans Nouv. Nes, p. 202. 



428 MUGUET. 

cover more or less of the mouth and fauces, as by a false membrane ; 
or, after disappearing for a short time, they may return and increase. 

This pellicle is of a white color when unstained ; but it is ocpasionally 
tinged yellow or reddish, as Billard has observed, by bile, or blood 
exuding from the mucous membrane, and this particularly in severe and 
fatal cases. 

It may occur at any period of infantile life (or at a later period), but 
it is more frequent during the first year, as the result of derangement 
of the stomach and bowels ; but when children of this age are crowded 
together, badly tended, and insufficiently nourished, then the disease 
displays itself in its severest form. 

If the mouth be carefully examined before it is entirely covered by 
the white pellicle, the intervening mucous membrane will generally be 
found more vascular than natural, dryer, of a brighter or deeper red 
color; and if we detach a portion of the pellicle, the surface underneath 
will be seen to be highly inflamed. 

In addition to the local condition of the mouth, there are few consti- 
tutional symptoms ; the child is uneasy, and may find it difficult or 
painful to suck; and, although very thirsty, the effort of drinking occa- 
sionally gives great pain, nay, in some cases, I have seen it impossible. 
This, perhaps, may be owing to the extension of the disease to the 
oesophagus, of which I shall speak presently. 

The skin is hot and dry, although the pulse does not seem to be much 
quickened. M. Billard "counted the pulse and beatings of the heart in 
forty children, aged from one to twenty days, affected with it, and found 
fifty, sixty, sixty-four, eighty, and, in one instance, 100 pulsations in 
the minute." 

The conclusions to which M. Bouchut has arrived are: "That there 
are two varieties of muguet, idiopathic and symptomatic ; that both 
depend upon the general condition of the individual ; the first upon a 
bad state of the constitution, and the second upon deranged health from 
organic disease ; that the only proper symptoms are the local ones, i. e. 
the condition of the mouth ; that the general symptoms depend upon 
the disease in the course of which muguet occurs ; that ordinarily they 
are those of enteritis, but that they may be those of pneumonia, tuber- 
cular phthisis, hydrocephalus, &c." 

The local phenomena, then, which characterize the disease, are pre- 
cisely the same, whether the latter be primary or secondary, but the 
general symptoms are often much more severe than I have described, 
especially when the disease is epidemic, in hospitals, or when it occurs 
as a secondary affection, as will appear presently. 

613. Pathology. — Careful and repeated investigation has established 
beyond dispute essential difference between muguet and aphtha. Mu- 
guet is not seated beneath the mucuous membrane generally, nor does 
it involve the destruction or disorganization of that tissue. It is a 
curdy matter deposited upon the surface, quite removable, and which, 
in fact, is constantly thrown off, leaving an unbroken surface beneath. 

What then is the matter, and how does it originate ? Opinions differ 
upon this point. M. Auvity and others have regarded muguet as a 
disease of the mucous follicles, but the minute researches of M. Lelut 



MUGUET. 429 

seem to have refuted this opinion, inasmuch as he never could detect 
any prolongation of the false membrane into these follicles, but found it 
perforated at their orifices; and this observation upon the living was 
abundantly confirmed by careful examination after death. 

614. M. Lelut describes two varieties of muguet: one, creamy, in 
patches, of a creamy consistence, easily removed by lotions or slight 
friction, and which is seated upon the mucous membrane ; the other in 
flocculi, irregularly filamentous, yellow, and either under the epithe- 
lium or at least so adherent to the mucous membrane that the latter 
may be removed with the deposit. Further, he concludes that this false 
membrane is analogous to other false membranes which are found in- 
ternally or externally, to the secretions of the mucous membranes, and 
to the epithelium itself; and this conclusion was attained by submitting 
each to the same chemical tests, with the same results. 

M. Lelut's researches would seem to prove that on the edges and 
inside of the lips and cheeks, and on the central portion of the palatine 
vault, the false membrane is beneath the epithelium ; but that on the 
other parts of the mouth and in the oesophagus it is either upon the 
epithelium, or, if originally beneath it, it rapidly so transformed it as 
to render it undistinguishable. 1 

M. Billard regards the deposition as coagulated mucus, and Guyot 
as mucus modified by excess of fibrin. 

615. M. Bouchut rejects the opinion of Lelut that muguet is analo- 
gous to other false membranes secreted by the mucous membrane, and 
considers that it is a vegetable parasite, formed according to the laws 
of spontaneous generation ; and he gives the following extract from the 
report of the Academie des Sciences, the exactness of which he states 
he has many times proved: "A portion of muguet being placed under 
the microscope, it is seen to be composed of a mass of cryptogamic 
plants. It consists of conical elevations of twenty-five millimetres in 
diameter, each one consisting of separate portions, provided with roots, 
branches, and sporules. 

" The roots are implanted in the cells of the epithelium ; they are 
cylindrical and transparent, of 1.400 of a millimetre in diameter ; and 
in their development they perforate each series of cells composing the 
epithelium to arrive at the surface of the mucous membrane. The 
trunks or stems which grow from the surface of the epithelium are 
equally transparent, interrupted at distances by divisions, and inclosing 
in their cavities corpuscles. Like the roots, they are cylindrical and 
rectilinear, 1.4 of a millimetre in length, and 1.400 of a millimetre in 
thickness. These stems are divided into branches, which again subdi- 
vide, bifurcating at a very acute angle. The branches are composed of 
oblong distinct cells, inclosing in their interior one, two, or three trans- 
parent knots (noyaux), their sides here and there exhibit sporules, of 
which there is a great number at their extremity. The diameter of 
these sporules is from 1.200 to 1.400 of a millimetre. These crypto- 
gamia have considerable analogy with the mycodermia of the porrigo 
favosa, and resemble the genus sporotriehium of botanists." 2 

1 Archives Gen. cle Med., vol. xiii. p. 360. 

2 Manuel Prat, des Mai. des Nouv. NtSs, p. 174. 



430 MUGUET. 

M. Bouchut agrees with M. Lelut as to the red and dry condition of 
the mucous membrane underneath the muguet, but differs from him in 
regarding the muguet as a growth upon the epithelium everywhere. He 
describes the mode of extension from the mouth to the pharynx, oeso- 
phagus, and stomach; and he mentions distinctly having seen the disease 
in the large intestine and around the anus, thus confirming the obser- 
vations of Lediberder, Billard, and Valleix. 

Dr. West observes : " I cannot pretend to decide, from personal ob- 
servation, the point at issue between the supporters of these two con- 
flicting theories, but my opinion decidedly leans to the adoption, as 
generally correct, of that view which sees in the deposit of aphthae and 
muguet the result of an inflammatory process ending in the formation 
of false membrane, wherein a parasitic growth may become developed." 

" The frequency of the parasitic growth in the false membrane is 
possibly dependent on the actual transplantation of its sporules from 
one patient to another, by means of the cups, spoons, &c, used by them 
in common, and generally without sufficient attention being paid to 
insure their perfect cleanliness. Whether, in any case, the deposit of 
these sporules upon the surface of the healthy mucous membrane is 
followed by the development of the confervae and the alteration of the 
epithelium of the mouth, is a question to which it is not possible at 
present to give a satisfactory reply. For my own part, I should greatly 
hesitate to answer it in the negative." 1 

Dr. Berg, of Stockholm, in a valuable work upon the thrush in 
children, but which appears to me to be rather a description of muguet, 
regards it as a parasitic disease, and has given at great length its mi- 
croscopic characters. " The white coating," he says, " consists of epi- 
thelium thickened by the swelling of its constituent cells, and from this 
epithelium there springs a parasitic fungus of greater or less quantity, 
so that the chief portion of a patch of aphthae is composed either of 
epithelium or else of parasitic growth. Now, the relative proportions of 
these two substances seem to depend upon the length of time that has 
elapsed since the growth of the parasite commenced, which varies in 
different children, and it is also in relation to the diversity of the epi- 
thelial thickening. More or less of molecular albuminous matter is 
also to be found in these patches. When the parasitic growth and the 
epithelial condensation is confined merely to the extremities of the 
smaller papillae (as at the point of the tongue), they have the appear- 
ance of small isolated specks, but when they appear upon portions of 
the mucous membrane where the papillae are less prominent, and where 
the intervals between them are filled by a denser epithelium, the white 
coating then assumes those forms of circles, of interlacing bands, or of 
hemispherical elevations, so frequently observed in parasitic vegetations, 
when they are permitted to increase freely without any mechanical 
obstacle to their growth. Lastly, when both the epithelial and para- 
sitic growths alike proceed vigorously, those spots which at first were 
isolated, coalesce more and more into a continuous covering, the cohe- 
sion of which is maintained not merely by the natural adhesion of the 

1 Diseases of Children, p. 337. 



MUGUET. 431 

epithelial cells, but also by the interlacing of the parasitic fibres among 
themselves and between the cells of the epithelium." 1 

Further, Dr. Berg concludes that, " 1. The aphthous parasite can 
propagate itself in appropriate menstrua out of the body, and this not 
only when the aphthous crust is mingled with various animal fluids, but 
also when completely separated and cleansed from these. 2. Its 
growth in such cases proceeds not only in a temperature equal to that 
of the human body, but likewise in one that is much lower. 3. Aphthae 
seem to require for their growth the presence of a body containing 
azote, such as albumen, as also that of materials for the generation of 
acid. 4. Out of the body, aphthge seem to develop themselves in two 
different forms, either in that of a great preponderance of sporules — 
when a white filmy membrane forms on the surface of the fluid — or, 
again, they appear chiefly as stems ramifying through the fluid or 
aggregated into a felt-like mass. A solution of potassa will always 
dissolve the molecular deposit of albumen, leaving the fibres and cells 
of the parasite totally unchanged. 

It is very pleasant to recollect that we may recognize and cure the 
disease, may in fact understand all about it practically, and control it, 
notwithstanding these microscopic difficulties and doubts. The im- 
portant facts we know are, that, as the result of an inflammation of the 
mucous membrane of the mouth or digestive tube, a deposition of curdy 
matter may take place in the mouth, or in other parts of the digestive 
canal, and that generally this matter is upon the epithelium, and does 
not involve the destruction of the subjacent membrane. 

616. Causes. — I have already alluded to the greater prevalence of 
this disease in the early months of life, at a period when the constitu- 
tion is peculiarly tender, the digestive tube scarcely reconciled to its 
new functions, and when mismanagement is no immediately and seriously 
injurious. Even under careful treatment we meet with it, but much 
more frequently when the infant is exposed to bad food, impure air, or 
insufficient clothing. 

I quite agree with the opinion of MM. Baron and Billard that the 
disease is not contagious in the ordinary sense ; but that it may be 
communicated by contact under certain circumstances, e. g. to the nip- 
ples of the nurse, I have no doubt, because I have seen it, and this 
agrees with the experience of MM. Guersent and Mariay. 

Dr. Berg considers the parasitic growth to be favored by the large 
proportion of sugar and starch in the food of children, and he believes 
that the disease may be conveyed from one child to another by spo- 
rules or fragments of sporules in the dried state, floating in the atmo- 
sphere, but that it is more frequently propagated by the bottles from 
which children having the thrush have been fed, or by the nipple, 
especially when two children are suckled by one nurse. He succeeded 
in propagating it also by applying aphthous crusts to the mucous mem- 
brane of the mouths of healthy children. 

It may also prevail either epidemically or endemically. In places 
where many infants are congregated, I may say it prevails at all times. 

1 British and Foreign Med. Review, vol. xxiy. p. 423. 



432 MUGUET. 

According to Billard " it prevails with almost equal intensity and at all 
times at the Hospice des Enfans Trouves. In the quarter ending in 
March, 1826, out of 290 patients, there were thirty-four cases of it. 
In the quarter ending in June, out of 235 patients there were thirty- 
five. In the quarter ending in September, out of 213 there were 101 
cases ; and forty-eight in^the quarter ending in December, among 189 
patients. M. Baron has seen it prevail among a number of individuals 
at certain periods, without being able to assign for its cause any influ- 
ence from temperature.'' 1 

617. But no doubt the most frequent cause is to be found in the 
primary affection to which muguet is secondary, and we shall now in- 
quire into these complications, and for this purpose I shall avail myself 
of the minute researches of M. Valleix. I am tempted, however, as a 
prelude, to give a short summary of his experience of the disease in 
twenty-four cases in the Infirmary of the Hospice des Enfans Trouves. 
All the infants were less than a month old, and were strong and vi- 
gorous. Most of them had been sent to the infirmary on account of 
pemphigus or pustules. In one only did muguet exist at that time, and 
there were no grounds for suspecting its communication to the others 
by contagion ; the less so, indeed, as one-fourth of the infants sent to 
the infirmary are so attacked. 

The appearance of the false membrane was preceded some days by 
an attack of erythema of the thighs. After the erythema had con- 
tinued for four or five days, diarrhoea supervened, at first moderate, 
but increasing rapidly, the evacuations being yellow at the beginning. 
At the same time the pulse was accelerated from 80 or 90 to 116, 130, 
or even 140 ; the face became pale and of a dull yellow color. 

To these symptoms were added most frequently (in nineteen out of 
twenty cases) a marked swelling of the papillae at the extremity of the 
tongue, and shortly after, a vivid redness of that organ which soon 
spread to the rest of the mouth. In eight cases ulceration of the palate 
occurred about the same time. The redness and swelling of the tongue 
indicated the invasion of muguet, the grains of which in twenty cases 
appeared on the first day. In seven cases they were developed at the 
same time on the inside of the cheeks, but commonly the tongue was 
the part first affected. At first a few grains were observed on the 
tongue, then irregular masses on the inside of the cheeks, and strips on 
the vault of the palate, and coalescing they formed a layer more or less 
thick. This morbid production was always white at first, and only 
became yellow towards the termination in five cases. It was at first 
adherent, and any attempt to detach it made the mucous membrane 
bleed, but afterwards it could easily be removed. During the develop- 
ment of the false membrane the former symptoms (erythema and diar- 
rhoea) persisted, and new ones were added. The stools almost always 
became green, but in no case could any portion of false membrane be 
detected in them. 

The heat of the mouth was rarely increased, but the tongue was dry 
in thirteen cases. 

1 Mai. des Enfans, p. 167. 



MUGUET. 433 

When the muguet was very abundant it occasioned considerable dis- 
tress, -which the infant evidenced by rolling about the tongue and 
moving the jaws, as though to remove some unpleasant substance. At 
the same time it refused the breast, and cried if the fingers were intro- 
duced into the mouth. 

Meteorism of the abdomen supervened in twenty cases: in four, 
previous to the appearance of the muguet ; in the remainder, during 
the greatest intensity of the disease ; and was attended by symptoms 
of colic, and in some cases by tenderness. Vomiting occurred in only 
five cases, and the matter ejected was sometimes yellow, sometimes 
colorless. After the diarrhoea had continued for some time, ulceration 
of the ankles or heels took place, the patient became agitated, inter- 
mittingly at first, but afterwards constantly, and the pulse became 
rapid. The heat of skin was in proportion to the quickness of pulse. 

" Towards the end of the disease, all the symptoms seemed to dimi- 
nish, but it was only to give place to collapse. The erythema became 
less vivid ; the ulcerations were covered with crusts ; the diarrhoea di- 
minished or ceased entirely; the infant refused the breast, and would 
scarcely drink ; the muguet diminished, and ordinarily consisted only 
of a few grains on the tongue. The pulse fell to 80, 70, or even 60 in 
a minute ; the heat was succeeded by chilliness, at first of the extremi- 
ties, and afterwards of the whole body ; the agitation gave place to 
almost complete insensibility ; the cries were changed into groans ; the 
emaciation and pallor became extreme, and the face acquired the ap- 
pearance of decrepitude. 

" About this period were developed in certain cases inflammations, 
not very acute, characterized by cedematous swelling, obscure redness 
and pain ; they occurred in the nose, lower lip, and neck. At this time 
also abscesses, occasionally numerous, were formed in different parts of 
the subcutaneous cellular tissue, and in one case gangrene of the inte- 
guments of the limb occurred. At last death closed the scene without 
pain." 1 

The mean duration of the disease was 17J days in the fatal cases, and 
16| in those who recovered. Three distinct periods were remarked. The 
first, from the commencement to the appearance of the muguet; the 
second, from this time to the termination of the febrile stage ; and the 
third, the. period of collapse. 

" Autopsy revealed various lesions. In nineteen cases false mem- 
brane was found in the mouth ; in ten the palate was ulcerated. The 
oesophagus was almost always occupied by false membrane, and in 
all the cases there were lesions of the gastro-intestinal mucous mem- 
brane, the result of inflammation. In a small number ulcerations were 
found. The liver, the spleen, the kidney, the bladder, the larynx, tra- 
chea, and bronchi, presented nothing abnormal, but in eight cases there 
was hepatization of the lungs. The circulating system was unchanged, 
except in one case. The skin and cellular tissue exhibited evidences of 
the lesions with which they had been affected." 

1 Clinique des Mai. des Enfans, &c, pp. 209, 210. 

28 



434 



MUGUET. 



I shall add M. Valleix's resumS of the special condition of the gastro- 
intestinal canal in twenty-two cases : merely premising, that, as far as 
the stomach was concerned, the localities of these morbid changes were 
as follows : — 

At the larger extremity, in 13 cases. 

On the anterior parietes, in 12 " 

On the posterior parietes, in 11 " 



At the greater curvature, in 
At the smaller curvature, in 



11 



I. As to the lining membranes of the stomach, there was found — 

1. Softening of the mucous membrane, with thickening and redness, or 

some other alteration of color, in 6 cases, i. e., 
Occupying almost the entire stomach, with redness, in . . 3 cases] 
Occupying a limited portion of the surface, with redness, in. . 2 " j fi 
Occupying a limited portion, with brown discoloration, and soften- 
ing of the other coats of the stomach, in .... 1 case J 

2. Softening, with redness, without thickening, occupying the entire "] 

extent of the stomach, in 3 cases L 5 

Occupying a limited portion, in 2 " J 

3. Softening, with neither redness nor thickening, occupying the entire 



extent of the stomach, 
Occupying a limited portion, in . 
Alterations of color without thickening or softening, 

General rose color, in 

General brown color, in .... 
Deep red color, punctated, in . 

No change in 

No data in 



2 " 
1 case 

5 cases 
1 case 
1 » 



II. As to the mucous membrane of the small intestines, there ex- 
isted — 

1. Extreme softening, with thickening and redness, in . 

2. Considerable softening, with thickening and redness, in . 
Considerable softening, with thickening, but without redness, in 
Considerable softening, with redness, but without thickening, in . 1 case. 
Considerable softening, with neither redness nor thickening, in . 2 cases. 

3. Slight softening, with thickening, but without redness, in . . 1 case. 
Slight softening, with redness, but without thickening, in . . 1 " 
Slight softening, with neither redness nor thickening, in . . . 4 cases. 

4. The natural color and consistence, in 



in. The condition of the mucous membrane of the large intestine is 
thus stated : — 

1. Extreme softening, with thickening, and of a punctated brown color, in 
Extreme softening, without thickening, and of a bright red color, in 

2. Considerable softening, with thickening and redness, in . 
Considerable softening, with thickening, but without redness, in 
Considerable softening, with redness, but without thickening, in 
Considerable softening, with neither redness nor thickening, in 

3. Slight softening, with thickening, but without redness, in . 
Slight softening, with redness, but without thickening, in . 
Slight softening, with neither redness nor thickening, in . 

4. The natural color, consistence, and thickness, in 



in 1 


case. 


1 


" 


2 


cases. 


4 


" 


2 


<< 


2 


" 


1 


case. 


2 cases. 


3 


" 


3 


«i 



It does not appear that M. Valleix was able to trace the false mem- 
brane further than the stomach in more than one or two cases ; Veron, 
Davies, Eberle, and Condie have not been able to trace it beyond the 



• Clinique des Mai. des Enfans, &c , p. 267. 



MUGUET. 435 

oesophagus, whilst Guyot and Billard have found it through the entire 
alimentary canal. I have seen a similar false membrane around the 
anus at the same time that it appeared in the mouth ; and though I 
have not traced it through the alimentary canal, I feel scarcely a doubt 
that it occasionally extends throughout. 

It would appear from these researches that muguet is chiefly second- 
ary to a diseased condition of the mucous membrane of the digestive 
tube, and that softening of the mucous membrane is the principal form 
of this disease. 

We have seen that children attacked by muguet may also suffer from 
pneumonia, as a complication, and occasionally they are attacked by 
bronchitis. 

618. Diagnosis. — There is no difficulty in the diagnosis when once 
the false membrane is formed, inasmuch as the only disease with which 
it can easily be confounded is aphthae, and from this it is distinguished 
by the integrity of the mucous membrane underneath the creamy depo- 
sition, and by the fact that the latter is seated upon the membrane 
generally; whereas, in aphthae, we shall have small grayish ulcers or 
pustules in the mucous membrane. 

Previous to the appearance of the muguet, the disease of the mucous 
membrane resembles some forms of gastro-enterite ; nor is it of conse- 
quence to make a very nice distinction, if it were possible, for in most 
cases the muguet is secondary to such an affection. 

619. Prognosis. — Idiopathic muguet, in tolerably healthy children, 
and uncomplicated with organic disease, is of short duration, and of 
comparatively little consequence. After a few days, the false membrane 
becomes thinner and less continuous, resembling in appearance the 
patches or points by which it commenced; by degrees it peels off, leav- 
ing the mucous membrane moist, and somewhat smoother and redder 
than natural ; and the little patient, relieved from the soreness and dis- 
tress in swallowing, appears quite recovered. In this simple form of 
the disease we do not meet with fatal cases. 

But it is not so when muguet occurs in dilapidated constitutions, or 
with extensive disorder of the alimentary canal, or in the course of 
chronic diseases ; the mortality is then considerable, resulting, how- 
ever, not so much from the muguet as from the primary disease, or 
from the complications. The affection of the mouth is important, as 
indicating the state of the constitution ; but it is to the primary affection 
that our attention should be directed. 

M. Baron had 109 fatal cases out of 140, M. Valleix twenty-two out 
of twenty-four, all of which labored under entero-colitis ; and, in addi- 
tion, eight of them had pneumonia and one meningitis. M. Bouchut 
observed forty- two cases in the Hopital Necker, fourteen of which were 
idiopathic, and of these none died. In the remaining twenty-eight, the 
muguet was symptomatic of visceral disease, and of these twenty died, 
fourteen of chronic entero-colitis, complicated in five cases with pneu- 
monia, four of acute entero-colitis, three of pneumonia, and one of hy- 
drocephalus. The remaining eight were affected with entero-colitis or 
phthisis, and left the hospital suffering from muguet. 

620. Treatment. — The two forms of muguet are so far different that 



436 MUGUET. 

the one is a local affection, dependent, no doubt, to a limited extent, 
upon the general condition of the child, whilst the other is secondary to 
some pre-existing disease — an additional symptom, in short, and little 
more — and of course the treatment will vary accordingly. 

In primary or idiopathic muguet, if the disease be slight, some mu- 
cilaginous wash, slightly acidulated, and applied with a brush, or a little 
honey placed on the tongue, with a gentle purgative now and then, a 
warm bath, pure air, and wholesome nourishment, will be all that is ne- 
cessary. 

If the child have been too early deprived of its natural food, or if the 
suck appear to disagree with it, it will be quite necessary to provide a 
healthy nurse for it. 

In some cases, we must add to the wash or to the honey either 
chloride of soda (one-fourth part), as Guersent and Darling recommend, 
or a small portion of alum, as Billard advises, or a little borax. 

M. Trousseau, at the Hopital Necker, uses equal parts of borax and 
honey with great success. I have found this extremely useful, but I 
prefer commencing with a smaller proportion of borax. 

Dr. Hecker recommends a solution of the sulphate of zinc, M. Dug&s 
a lotion containing the vegetable acids, and M. Bretonneau the applica- 
tion of a powder consisting of half a grain of calomel triturated with a 
few grains of sugar, three or four times a day. Dr. Condie prefers 
borax rubbed up with white sugar. 

Alkaline remedies are favorites with Dr. Berg, as he found them 
arrest the formation of the parasite, and at the same time soften the 
epithelium and aid in throwing off the crusts ; but after this treatment 
has been employed for some time, he advises a change to acid and 
astringent applications. 

In some obstinate and severe instances, it may be necessary to apply 
stronger remedies, such as nitrate of silver in solution (gr. x or gr. xx 
to oj), or muriatic acid and water or honey (5j of the former to oj of 
the latter). 

621. In all these cases, it will be advisable to give small doses of the 
hyd. c. creta, with rhubarb, two or three times a day, so as to act gently 
upon the bowels, unless diarrhoea should be present, in which case chalk 
mixture, or mucilage and water, with a drop or two of laudanum to the 
ounce, and a few grains of aromatic confection, will form a useful mix- 
ture, of which a teaspoonful may be given three or four times a day. 
When the looseness of the bowels is corrected, we may then commence 
with the mercury and chalk. 

In the cases where the constitution of the child is much deteriorated, 
I have found great benefit from small doses of quinine, say one-third 
of a grain three times a day ; and it may be combined with the pow- 
ders already mentioned, or given separately. 

The diet must be carefully superintended. In many cases, the infant 
cannot suck ; it must, therefore, be fed with a spoon. Milk, alone or 
with water, arrowroot, gruel, with a little wine whey occasionally, will 
be their best food. Older children will require that their food should 
be nourishing and soft, so as not to irritate the inflamed mucous mem- 
brane. 



APHTHA. 437 

As the false membrane is only an accidental accompaniment in second- 
ary muguet, our first care must be directed to the primary disease, and 
the local affection of the mouth will follow its course, diminishing or 
increasing according to its state. 

The local remedies just named may be used, but success with the 
mouth will mainly depend on our curing the primary complaint. Of 
that, I shall speak hereafter. 



CHAPTER V. 



APHTELE. — THRUSH. — FOLLICULAR STOMATITIS. 

622. Aphthae, or thrush, is a very common disease of infancy and 
childhood, and has been noticed by most writers from very early times ; 
for instance, it is mentioned by Hippocrates, Galen, Aretaeus, and Cel- 
sus, and in our own country by Harris, 1 Moss, 2 Rosenstein, 3 and since 
then by all writers on diseases of children. 

The earlier descriptions, however, were so far inaccurate that they 
confounded muguet with aphthae, and simple thrush with ulceration, or 
even gangrene of the mouth. 

Like muguet, aphthae of the mouth may occur at any period of infan- 
tile life from birth, or it may attack adults, but certainly it is more fre- 
quent in children under four or five years of age ; and this we should 
expect, because it appears to be dependent upon some derangement of 
the digestive system, and the stomach and bowels are more apt to be 
disturbed in early life than subsequently. Denis 4 and Billard 5 regard 
muguet as more common with young infants, and aphthae about the 
period of the first dentition. 

623. Symptoms. — The symptoms will naturally vary according to the 
extent of the disease, which may be confined to the mouth, and exhibit 
either few and distinct or numerous and confluent aphthae, and also 
according as the affection is primary or secondary. 

Take, for example, the case of a child in pretty good general health, 
whose mouth has become thus affected. We shall find a few vesicles or 
small ulcers, if the top have been rubbed off; and the mother is sure to 
direct our attention to the prominent fact that the infant does not like 
to be fed, that it cries, and resists sucking still more, or, perhaps, that 
it positively refuses to suck at all. 

This is not to be wondered at, for nothing could be better calculated 
to give the child pain, except, perhaps, the scouring the nurses give the 
mouth by way of cure. 

1 De Morbis Infantum, p. 81. 

2 On the Management and Nursing of Children, &c, p. 185. 

3 On the Diseases of Children, p. 27. 

4 Recherches des Mai. des Nouv. Nes., p. 109. 

5 Traite des Mai. des Enfans, p. 213. 



438 APHTHA. 

The mouth is extremely hot, the lips often swollen, and the saliva 
constantly dribbling, partly from its excessive secretion and partly from 
the difficulty of swallowing. The breath is often very disagreeable, and 
the bowels will generally be found to be out of order. In the milder 
cases, however, there is no fever or constitutional disturbance. 

624. But when the aphthae are numerous and confluent — when they 
extend into the oesophagus, and when, as generally happens in such cases, 
the primary disease is severe, and has broken down the health of the child, 
then the case presents another aspect altogether. 

The appearance of the patient changes ; it becomes pale and anxious, 
with a restless, fretful, and distressed expression, irritable and whining, 
unable to suck or to swallow without great pain, if at all. It becomes 
greatly emaciated; the stomach and bowels show signs of great disorder, 
partly from irritation, and partly from want of proper nutrition ; vomit- 
ing is frequent, and diarrhoea almost constant, with watery or green- 
colored stools. 

The skin is hot and dry, the mouth hot, swollen, red, and covered 
with aphthae, the dribbling is excessive, and the pulse quick but feeble. 

When the disease extends to the pharynx, the glands are apt to en- 
large, and the irritation or inflammation may extend to the trachea, 
altering the character of the voice, and rendering it harsh or hissing. 

When the thrush is secondary, or when complicated with other or- 
ganic affections, the symptoms of the primary or secondary disease 
may predominate, so that the thrush will appear merely as an aggrava- 
tion. 

625. Pathology. — I have already stated that muguet and aphthae 
differ, in that the former is a vegetable growth deposited upon the sur- 
face, and the latter an ulcerative process beneath the epithelium. 

Dr. Bateman defines the disease thus: "The aphthae are small whitish 
or pearl-colored vesicles, appearing on the tongue, the lips, and the in- 
terior surface of the mouth and throat, generally in considerable num- 
bers, proceeding to superficial ulceration, and terminating by an exfo- 
liation of white crusts." 1 

Some writers have classed them as pustules, others as ulcers, with- 
out investigating their seat. Bichat, with his usual acuteness, started 
the question as to whether they were an affection of the chorion of the 
mucous membrane, or of the papillae, or of the follicles; a question 
Avhich Gardien hesitated to answer, but upon which the researches of 
Billard have thrown much light. He regards the disease as an inflam- 
mation of the muciparous follicles of the mucous membrane. In an 
early stage of the inflammation, " they appear on the internal surface 
of the lips and cheeks, on the pillars of the velum, and the palatine 
arch, and the inferior surface and lateral parts of the base of the tongue, 
under the form of small white points, sometimes exhibiting a colored 
spot in their centre, slightly prominent, and often surrounded by a 
slightly inflammatory circle." "The follicular points enlarge, pre- 
serving also their circular primitive form, and from their central aper- 
ture there soon issues a white matter, which is at first compressed by 

1 On Cutaneous Diseases, p. 263. 



APHTHA. 439 

the epithelium, but which escapes on that membrane becoming ulcerated. 
The follicle, when ruptured, is no longer a prominence, but a superficial 
ulcer with rounded edges, sometimes sharply defined, more or less 
tumefied, and almost always surrounded by an inflamed circle, of a fiery 
red. The border and centre of this slight ulcer often secrete a white 
pultaceous matter, like a slight scab, which is separated and expelled 
with the saliva." 1 

Berg, Robin, Gruby, and Green, 2 however, consider the disease as a 
vegetable growth, the spores of the plant adhere firmly to the isolated 
or imbricated epithelial cells, and that the number of spores greatly 
exceeds the filaments. 

The vesicular or pustular character of the aphthae, then, appears to 
be owing to the limitation by the epithelium of the space occupied by 
the white matter issuing from the follicular orifice, and certainly the 
appearance is sufficiently exact to justify Bateman's description. The 
distinctive character which is practically important, appears to be the 
small ulcer with its inflamed base. 

These aphthaa appear first on the edges of the tongue, the angles or 
inside of the lips, from whence they spread with more or less rapidity 
over the tongue and inside of the cheeks to the fauces; and as they will 
be found in different stages, the mouth acquires the appearance of irre- 
gular superficial ulceration with white cream-colored sloughs. 

626. That the oesophagus and even the stomach may be thus affected 
is admitted by most writers, but they are not agreed as to whether the 
disease may extend lower. Moss 3 and Underwood 4 notice the appear- 
ance of aphthae at the anus, and assume this as a proof that the dis- 
ease extends through the bowels ; and Bateman mentions that such 
extension of the disease is supposed to take place, but very properly 
observes that the redness and partial excoriation about the anus, so 
frequently observed in the complaint, may be owing to the acrid nature 
of the discharges from the bowels. 

Armstrong* states that from the oesophagus " it is continued quite 
through the stomach and intestinal canal to the anus, at least it makes 
its appearance very plainly at this part." Marley observes : " I saw 
a case some time since, where I had little doubt but that the disease ran 
its course to the verge of the anus ; 6 and Gardien mentions this exten- 
sion as a fact well known. 

Dr. Bateman notices that the trachea is occasionally affected with 
aphthae, but that they very rarely extend to the nose. 

When the aphthae are numerous and coalesce, covered by the white 
sloughs, they resemble and may be mistaken for muguet, but a little 
care will avoid this error, for in the latter no ulceration can be dis- 
covered, and it is plain enough in the former, notwithstanding the crusts, 
and moreover we shall be able in some part of the mouth to detect the 
enlarged follicle before exudation has taken place. 

627. These small aphthous ulcers may assume a more extended and 

i Mai. des Enfans, p. 209. 2 Med. Times, July 2G, 1851. 

3 On the Management and Nursing of Children, p. 188. 

4 Diseases of Children, p. 155. 5 Ibid., p. 24. 
6 Ibid., p. 52. 



440 APHTHA. 

formidable state of ulceration, and even become gangrenous ; but there 
is an appearance which has been mistaken for gangrene, against -which 
we should be on our guand. Billard thus describes it : " Sometimes, 
when the follicular points are ulcerated, the borders of the ulcers, in- 
stead of being covered with a slight creamy exudation, exhale a small 
quantity of blood, which ^concretes under the form of a slight brown 
scab, mistaken by some authors, as in malignant sore throat, for a gan- 
grenous eschar." "Before pronouncing these eschars to be gangrenous, 
the nature and causes of the brown scabs covering the aphthous ulcera- 
tions should be examined with the greatest care. This mistake might 
produce very serious consequences, for we might be led to treat with 
stimulants and tonics a disease which it would be more rational to treat 
by simple antiphlogistic remedies." 1 

628. Causes. — We find the disease most common in pale, delicate, 
and unhealthy children, whose constitutions have been injured by 
neglect, bad food, vitiated air, want of cleanliness, and over-crowded 
habitations. It is not unfrequent with spoon-fed infants, and, as we 
might expect, it prevails very extensively in hospitals for children and 
foundling hospitals. Dr. Hamilton is of opinion that thrush is induced 
by "specific contagion," and Marley and others speak of the disease 
being excited in infants who had sucked from a breast previously used 
by a child so affected. 

It is said to have prevailed epidemically in some parts of Holland. 

But though occasionally a primary affection, it is by far more fre- 
quently secondary to an affection of the alimentary canal, similar to 
that in muguet, or it is the result of deteriorated health and constitu- 
tion resulting from various diseases. 

629. Prognosis. — From what has been said, it is pretty clear that, 
when aphthae are a purely local complaint, occurring in a tolerably 
healthy subject, few in number and distinct, there is no danger to the 
child. With proper treatment the white crust will fall off, and the little 
ulcer heal in a few days. 

This is not the case in the severe form of the disease. The child is 
in great danger from the suffering, the want of food, the vomiting, and 
diarrhoea; if these be not checked, it will run down rapidly beyond the 
reach of assistance. Add to this the danger arising from the primary 
disease, or from subsequent complications, and it is evident that the case 
is a very serious one. i 

The extension and coalescence of the aphthae, the dark color of the 
crusts, the unhealthy appearance of the small ulcers, the emaciation, the 
small quick pulse, &c, are very unfavorable symptoms. 

630. Treatment. — Dr. Bateman observes very truly, that "in the 
milder degrees of aphthae lactantium, slight remedies are sufficient to 
alleviate or remove the disease. The acidity in the first passages is often 
readily corrected by some testaceous powder, which, if the bowels be 
not irritable, may be joined with a little rhubarb or magnesia, or by the 

'pulv. contrayervse co. if they are in the opposite state and weakly. 
At the same time the nutriment of the patient should be regulated by 

1 Mai. des Enfans, p 211. 



APHTHA. 441 

attending to the diet and general health of the nurse, or, if the child he 
not suckled, bj procuring a wet-nurse, when that is practicable, which 
often speedily cures the complaint." 1 

If the surface of the mouth be very irritable and tender, the first local 
applications should be of a bland and soothing character: a little cream, 
or the yolk of eggs mixed with a little syrup of poppies, as recommended 
by Van Swieten; or the lips and tongue may be lightly covered with pure 
almond oil. 

By degrees, and in proportion to the decrease of the soreness, astrin- 
gents may be applied, and of these perhaps the best is the borate of 
soda mixed with powdered sugar or honey. Dr. Armstrong speaks very 
highly of a " solution of white vitriol in barley-water," in the propor- 
tion of half a scruple of the former to eight ounces of the latter at first, 
and gradually increasing its strength. For very young infants the juice 
of boiled turnips sweetened with sugar or honey. Etmiiller and Dr. 
Shaw advise honey of roses and spirit of vitriol or sea salt, but Under- 
wood thinks no application superior to borax and honey. 

631. In severe cases of the disease the same astringents may be used 
locally, or we may wash the mouth with a weak solution of the nitrate 
of silver, which I have found beneficial ; but unless we can change the 
state of the constitution we shall do but little good. For this purpose, 
if the child be still at the breast, the nurse should be changed ; or the 
food, if the child be weaned. In addition to milk, barley, bread jelly, or 
arrowroot, we may give wine whey or wine and milk pretty freely. For 
older children we may order chicken broth. 

If the stomach do not reject medicine, we may prescribe the hyd. c. 
creta\ with rhubarb if the bowels be costive, or with the pulv. cretse co. 
c. opio if diarrhoea be present. A drop of laudanum in milk, once or 
twice a day, will often quiet the bowels when more bulky medicine only 
irritates. If there be much vomiting, it will be better to administer 
these or analogous medicines by the rectum, and employ the stomach 
for nutriment only. 

Dr. Armstrong and others recommend us to commence by an emetic 
followed by a brisk purgative, but this will entirely depend upon the 
condition of the child when we first see it. If the stomach be loaded 
and the bowels confined, it may do very well, but in the majority of 
cases, especially if at all advanced, it would be somewhat hazardous. 

The following case, related by Marley, 2 is a good illustration of the 
value of Dr. Armstrong's suggestion in certain cases: "It occurred in 
a child about two years and a half old. The aphthae were from the 
commencement of a brownish hue, and in the course of a day or two 
became nearly black; the teeth were loaded with a brownish fur ; there 
was a copious flow of saliva; the breath was remarkably offensive, re- 
sembling much that of a person in a state of salivation ; the pulse was 
of a quick and jerking nature; no appetite whatever; in fact, the mere 
appearance of food produced a sensation of nausea. There was uni- 
versal lassitude. In this case I commenced with a dose of castor oil, 
which was retained on the stomach and operated well. This was fol- 

1 On Cutaneous Diseases, p. 267. 2 Diseases of Children, p. 53, 



442 ULCERATED SORE MOUTH. 

lowed the next day by an emetic, which brought away an almost in- 
credible quantity of bilious matter for so young a child, after which I 
treated the case with bark and ammonia. The only local application 
used was a lotion composed of decoction of bark and muriatic acid. 
The case got well." 

" When the aphthae assume a brown hue, or appear in a state of de- 
bility consequent on acute diseases, the general strength must be sup- 
ported by light tonics and cordials, with proper diet, such as a weak 
decoction of cinchona or cascarilla, or the solution of the tartrate of 
iron, with rhubarb, light animal broths, and preparations of milk with 
the vegetable starches." 1 

Chlorate of potash may also be given in doses of from two to five 
grains, three times a day. 

Dr. Hamilton very properly lays great stress upon cleanliness, ad- 
vising that the child should be washed all over, and a clean dress put on 
every twelve hours. 

If the anus should become excoriated, as often happens, it should be 
washed four or five times a day with warm water, and, after being dried, 
may be bathed with lead lotion or black wash, or powdered with lapis 
calaminaris, or anointed with zinc cream. 



CHAPTER VI. 

ULCERATED SORE MOUTH — ULCERATIVE STOMATITIS. 

632. At first sight there appears a similarity almost amounting to 
identity between this disease and aphthae, but in the latter the disease is 
limited to the muciparous follicles, the ulceration commencing around 
their orifices ; in the former the inflammation of the mucous membrane 
may run on into ulceration at any part and in an irregular manner. 
Aphthae occur also in young infants, but Rilliet and Barthez have found 
ulcerated sore mouth more common after five years. 

633. Symptoms. — According to M. Taupin, 2 the disease commences 
in the gums, which are swollen, red or violet, bleeding, and soon cover- 
ed with a soft layer of grayish matter. From the gums the' inflamma- 
tion and ulceration spread to the corresponding portion of the mucous 
membrane lining the mouth and lips, the small whitish spots by which 
it commences enlarge and coalesce until they form the large gray patches 
covering the erosion or ulceration. 

Generally speaking, the lesion is of small extent, affecting the gums, 
and exhibiting a few patches inside the cheeks or lips, more frequently 
one side than both, and oftener, the left than the right, according to 

1 Bateman on Cutaneous Diseases, p. 268. 

2 Journal des Connois. Med.-Chir., No. 10, April, 1839. 



ULCERATED SORE MOUTH. 443 

Rilliet and Barthez ; but in some rare cases it is much more extensive, 
involving the vault of the palate, as well as the other parts of the mouth. 

If the treatment fail and the inflammation persist, the patches in- 
crease in thickness by the secretion of additional layers, and the ulcer- 
ation deepens ; the layers of false membrane are detached and quickly 
renewed, and thus the disease is perpetuated. If, on the contrary, the 
inflammation diminish, the patches are thrown off, the ulcers become 
cleaner and fill up, and their raised borders subside. Then the epithe- 
lium is reformed, and there, remains only a deeper redness, marking the 
situation of the ulceration. 

M. Taupin states that the mucous membrane in these places remains 
thickened and somewhat hard, but Rilliet and Barthez regard the sub- 
mucous tissue as the seat of this thickening. 

The submaxillary glands are swollen, and if the attack be severe 
they become hard and painful, but the surrounding cellular tissue does 
not participate in the inflammation. The breath is generally offensive, 
and when the disease is extensive the odor is not unlike or much infe- 
rior to what we observe in gangrene. 

In severe cases we find externally considerable swelling correspond- 
ing to the ulcerations, and when pressed it feels soft, quite unlike the 
hard, resisting, circumscribed swelling in gangrene; the skin is neither 
smooth, nor shining, nor hot. 

More or less salivation attends the complaint. If severe, the mouth 
is kept open, the lips protruding, and the saliva dribbling over the 
swollen and ulcerated surface. This appearance is very characteristic 
of the disease. 

634. The suffering is very considerable ; the child is restless and 
uneasy, moaning, and putting its fingers to its mouth, and finding it 
more or less difficult to eat or drink. In severe cases, with infants, 
sucking is out of the question, and the child can only be nourished by 
the spoon. 

There is almost invariably some derangement of the stomach and 
bowels, often preceding, always following, the affection of the mouth. 
Occasionally the symptoms of entero-colitis are very marked, and such 
complications, whether primary or secondary, not only augment the 
distress and suffering of the patient, but materially influence his condi- 
tion and add to the danger. 

When the inflammation is moderate, the heat of skin will be natural 
and the pulse unaltered; but when of considerable extent and intensity 
we shall find more or less fever, with a quick and rather weak pulse, 
loss of appetite, disordered bowels, emaciation, &c. 

The disease may be prolonged for some time, although, generally 
speaking, it is not very tedious. Much will depend upon the constitu- 
tional condition of the child, upon the primary or secondary complica- 
tions, and upon the extent and depth of the ulcerations, the deeper ones 
requiring more time to fill up: moreover, the child is very liable to re- 
lapse. 

635. Pathology. — The disease commences as stomatitis, as already 
described. The mucous membrane of the mouth is swollen, inflamed, 
and hot, sometimes of an equally diffused redness, sometimes in patches ; 



444 ULCERATED SORE MOUTH. 

the gums are also swollen, red, and spongy. After the inflammation 
has continued for some time, we find a number of small whitish, or yel- 
lowish patches, slightly prominent. Beneath the epithelium, which is 
thicker than natural, we find these whitish points to consist of a pseudo- 
membranous secretion, similar to that found in the pustules of smallpox 
on the eighth or ninth day. This concretion is pretty firmly adherent 
to the subjacent parts, and covers a small ulcer with irregular borders 
which bleed when touched, and of uncertain form, sometimes round, 
sometimes longitudinal. 1 

If the disease increase, this false membrane forms a yellow, broad, and 
thick layer, underneath which we find a co-extensive superficial erosion 
of the mucous membrane. 

This is the milder form of the complaint. If not checked, the ulcer- 
ation deepens, the edges are red or of a violet color, and the surface 
covered with a reddish-gray layer. When the gums are mainly affected 
they appear red or violet, swollen, softened, bleeding, and covered with 
a pultaceous secretion. The ulceration spreads transversely, and is 
rather narrow, and by the destruction of the gingival tissue, the teeth 
are loosened, and sometimes fall out. 

The ulcerations of the tongue and inside of the cheeks are of a rounded 
form ; those of the lips and their commissure are longitudinal and spread 
rapidly. 

636. Causes. — Although an infant may be the subject of ulcerated 
sore mouth, yet both M. Taupin and MM. Rilliet and Barthez state that 
they have found it more frequent in children from five to ten years of 
age than at any other period, and in boys than in girls. 

Like other kindred affections of the mouth, it may appear at the time 
and connected with dentition, and it may be dependent upon a disor- 
dered state of the stomach and bowels, or a deteriorated constitution, 
which in children so certainly results from insufficient or improper food, 
want of cleanliness, vitiated air, damp or unwholesome dwellings, or 
the crowding together too many individuals in too small a space. 

It may also occur in the course of other acute or chronic disorders, 
as pneumonia, eruptive fevers, &c, which entail constitutional injury. 

It is endemic in certain wards of the Hopital des Enfans Trouves, 
according to M. Taupin, who also believes it to be contagious, i. e. to 
be communicable by using the same spoon for feeding, &c. 

And occasionally also it appears to prevail as an epidemic. 

637. Treatment. — The first indication is to remove the predisposing 
and exciting causes if possible. Thus if the child be young and have 
been spoon-fed, we ought to procure a wet-nurse for it, if it be not too 
old to suck; and if already weaned, the food should be changed. If it 
occur at the period of dentition, the gums should be freely scarified, and 
the child removed away from its companions to a dry, airy apartment, 
and kept scrupulously clean. 

Even if the teeth are -complete, we shall often derive benefit from 
slightly scarifying the gums ; or, if the inflammation be severe, apply- 
ing a leech or two to other parts of the mouth. 

! Taupin, Jour, des Connois. Med.-Chir., No. 10, April, 1839. 



ULCERATED SORE MOUTH. 445 

If this be not necessary, or after it have been done, the mouth should 
be carefully washed by means of a syringe and warm water, or a piece 
of lint dipped in water; we shall then be able to judge accurately of 
the state and extent of the ulcerations. 

In slight cases it will be sufficient to wash the mouth with emollient 
or mucilaginous or slightly acidulated lotions, or to apply powdered 
sugar, or a weak mixture of borax with honey or sugar. 

If these milder remedies fail we may try M. Bonneau's plan, and 
apply the dry chloride of lime or powdered alum. The end of the finger, 
or the end of a small roll of linen, should be moistened and dipped in 
the powder, and gently rubbed over the ulcers twice a day, and this 
application must be continued until the surface is healthy and beginning 
to heal. The mouth should be cleaned with a syringe and water a few 
minutes after each application. In ordinary cases I have found the 
borax and honey in the usual proportions answer the purpose exceedingly 
well. 

Dr. West regards the internal administration of the chlorate of pot- 
ash as almost specific. He prescribes from three to five grains, dissolved 
in water and sweetened, every four hours — previously giving a purgative, 
if the bowels be confined. 

638. But in very severe cases, before applying the borax and honey 
or alum, it will be necessary to touch the surface of the ulcers with 
nitrate of silver, or even muriatic acid, or the acid nitrate of mercury, 
and, after the slough has separated, then to have recourse to the milder 
applications. 

It sometimes happens that a carious tooth, though it may not have 
originated the inflammation, will certainly augment and perpetuate it. 
In such cases, it will be advisable to have it removed, as a preliminary 
to other treatment. 

Very great attention must be paid to the state of the stomach and 
bowels. If disease exist there, it will be in vain that we treat the 
mouth judiciously if that be neglected. Purgative medicine may be 
necessary, or diarrhoea may require to be checked; and if there be 
evidences of more serious disturbance, for example, of entero-colitis, it 
must at once be treated in the way we shall mention hereafter. The 
same may be said of every other complication, whether primary or 
secondary. 

The diet must depend a good deal upon the state of the constitution. 
If the child be exhausted or broken down, broths may be given freely, 
and wine whey may be necessary ; but if it be a local affection merely, 
and the child otherwise robust and healthy, moderate or even low diet 
will be advisable. 



446 GANGRENE OF THE MOUTH. 



CHAPTER VII. 

GANGRENE OF THE MOUTH. — CANCRUM ORIS. — GANGRENOUS STOMATITIS. 

639. This very formidable disease has been noted more or less cur- 
sorily by the older writers ; for instance, by Butter, in the sixteenth 
century; Van der Voorde, -who called it waterJcanker ; Van Swieten, 
who gave it the name of gangrene; Boot, Berthe, Dease, &c. ; but we 
are indebted for our more accurate knowledge of the disease to the re- 
searches of Baron, Isnard, Guersent, Constant, Taupin, Richter, Cu- 
ming, Duncan, Hueter, Rilliet and Barthez, &c. 

It has been described under various names, as water-canker, noma, 
gangrene of the mouth, cancrum oris, stomacace, necrosis infantilis, can- 
cer agneux des enfans, &c. 

640. Symptoms. — Mr. Cooper gives the following definition of the 
disease: "A deep, foul, irregular, fetid ulcer, with jagged edges, on the 
inside of the lips and cheeks, attended with a copious flow of offensive 
saliva. It is a perfect specimen of phagedenic ulceration, and in its 
worst forms not unlike hospital gangrene, as I have seen in several 
deplorable instances. It also resembles the ulceration and sloughing 
in the mouth produced by mercury." 1 

There appear to be several phases of the disease, differing in degree, 
if not more essentially. One variety is described by Dr. Cuming, of 
Armagh, as occurring in children between twenty months and seven 
years of age. " The ulceration commences generally in the gums, from 
whence it extends to the lips or cheeks. Sometimes it is of an acute, 
sometimes of a chronic nature, and as it approaches to one state or the 
other it is more or less attended by sloughing. In the very worst 
cases, however, though the sloughing is considerable, the ulceration is 
always predominant, and by its means the destruction of parts is prin- 
cipally effected. This form of the disease, which seems to answer to the 
affection described as cancrum oris by authors, bears a resemblance in 
some respects to the ulceration and inflammation of the mouth produced 
by mercury." 2 

I must say that this form of disease hardly deserves the name of gan- 
grene ; it appears to me rather to have been an aggravated form of the 
ulcerative stomatitis first described. 

Another variety has been described by Richter 3 and others, in which 
we find spots of gangrene, limited in extent, at the angles of the lips 
or upon the cheeks, occurring suddenly and with little general disturb- 

1 Surgical Dictionary, p. 332. 

2 Dublin Hospital Reports, vol. iv. p. 341. 

3 British and Foreign Med. Rev., vol. vii. p. 470. 



GANGRENE OF THE MOUTH. 447 

ance. In some instances, there is a red spot for a few days preceding 
the gangrene. When the sloughs separate, we see that the gangrene 
was but superficial, there being very little loss of substance. Such cases 
are apt to occur after acute affections of the skin, as measles, scarlatina, 
smallpox, &c, and generally heal without trouble. 

Dr. Marshall Hall has published six cases, in five of which the dis- 
ease commenced externally in the lip or cheek: " In one case the pa- 
tient did not survive the extreme irritation of the system in general, 
which attends the commencement of this affection : in four others life 
was prolonged until a considerable portion of the soft part of the face 
and mouth was destroyed by mortification, and the latter patients died 
from exhaustion. In a sixth the patient survived the affection alto- 
gether, after experiencing an extensive sphacelation of each cheek, of a 
part of the tongue, and of the contiguous gums, and even of a portion 
of the jaw-bone." "In this disease frequently, when the little patient 
has appeared to be convalescent from the previous indisposition, some 
part of the face has been affected with pain, induration, swelling, and 
erythema, and the child has become cross, irritable, feverish, and rest- 
less. At no distant period, usually on the succeeding day, a dark purple 
or livid spot has appeared, which has soon assumed a dark brown colour, 
losing its purple hue, and at the same time its vitality. When the pa^ 
tient survives, the sphacelated part enlarges and becomes black, sepa- 
rated, loose, and extremely fetid ; the living part retains an erythematous 
redness, bordered by a ring of a livid hue. The internal mouth is soon 
involved in the affection, the sphacelus spreading into this cavity ; the 
teeth become loose and eventually fall out, and the breath is shockingly 
offensive. The child, from being restless, becomes more tranquil and 
patient ; it seems frequently conscious of the disgusting appearance of 
the affection, and dislikes to be noticed ; but there is often eventually 
dozing or coma. In the latter stages there is not much heat of skin, 
but the pulse is frequent. 1 

My friend, Dr. Duncan, of this city, has more recently published a 
very interesting account of an epidemic resembling this disease which 
occurred in the North Union Workhouse : — 

" The age of the patients varied from about a year and a half to five 
years. I have no reason to believe it infectious, but in more than one 
instance it attacked a second member of the same family. Generally 
speaking, the attack was preceded for some days by diarrhoea, but, 
from the period of life corresponding often with the occurrence of den- 
tition, this feature was not always sufficient to attract the attention of 
the mother, and little was done to arrest its progress till the condition 
of the mouth was observed. The children at first did not seem to suffer 
pain in the bowels, and would bear the usual pressure of manual exa- 
mination, without inconvenience. The alvine evacuations were usually 
unhealthy, but they differed in appearance in different cases. Some- 
times they were thin and watery, but not deficient in bile : more gene- 
rally they were whitish and exceedingly offensive ; and in almost all of 
them blood was discharged, either in a fluid state or mixed with a jelly - 

1 Edinburgh Medical and Surgical Journal, vol. xv. pp. 547-8. 



448 GANGRENE OF THE MOUTII. 

like mucus. When this diarrhoea had continued a -week or ten days, 
the mother would mention that the child had a sore mouth, and on exa- 
mination it would be found that the gums were ulcerated and the fangs 
of the teeth exposed, and covered with a yellowish-white sordes. Ac- 
cording as the disease advanced the gums lost their pale flesh color, 
and became red, swelled, and spongy, and the margins exhibited a 
tendency to bleed, both spontaneously and on being touched." " The 
breath gradually became offensive, and the secretion of the salivary 
glands increased, so that the saliva used at times to flow from the mouth, 
and even to wet the pillow on which the patient lay. Partly from the 
attending fever, but principally from the tender and inflamed state of 
the gums, the children were unable to take food, but their thirst Avas 
often excessive. In no instance did I observe the teeth to fall out, pro- 
bably because, in fatal cases, death took place from the constitutional 
Irritation running so high before the local affection had time to produce 
its legitimate effects." " At first the disease did not appear urgent, but 
as soon as ulceration of the gums took place, and especially if appro- 
priate means to arrest its progress were not adopted, it advanced with 
considerable rapidity to a fatal termination. When this event occurred, 
it seemed due rather to the violence of the attending fever, or the in- 
tractable persistence of the diarrhoea, than to any peculiar changes 
effected in the condition of the mouth. In some of the cases the dis- 
ease seemed to be arrested for a time, the diarrhoea being completely 
checked, the alvine evacuations improved, the appetite restored, and 
every symptom of permanent convalescence being visible, when, after a 
time, the former symptoms would return in a severer form, and, resist- 
ing all measures of a remedial nature, hurry the victim to the grave. 1 
Even this epidemic can hardly be considered as a severe form of this 
disease : if it were more than severe ulcerative stomatitis, it was a com- 
paratively mild form of gangrene. 

At the risk of being tedious, I am tempted to extract a very graphic 
description of the local phenomena of this disease, by M. Wunderlich. 2 
He describes two forms. In the first, "the disease directly shows itself 
to be gangrene. This is noma, using the word in a limited sense, or 
stomatite charbonneuse of Taupin. One-half of the face (usually the 
left) exhibits an indistinctly defined pale or violet marbled swelling, 
especially on the eyelids, with a peculiar oily appearance of the skin. 
An erysipelatous redness of the cuticle is also frequently observed. 
The inner surface of the cheek is livid and of a dark red color. A 
small vesicle (which is often overlooked) now appears, generally on 
the outer surface of the cheek, near the mouth, but sometimes on the 
mucous membrane, and lying on a hard, dark red, and often livid ground ; 
this vesicle shortly bursts and becomes converted either into a superfi- 
cial erosion, or a deepish ulcer, which usually becomes soon covered 
with a slough of considerable size, measuring in diameter from several 
lines to an inch. It occasionally happens that there are several distinct 
points of origin of the morbid process, which either unite or remain 
isolated. The hardness and oedema of the surrounding parts increase 

1 Dublin Journal, vol. xxviii. p. 3. 

2 Handbuch des Pathologie und Thcrapie, vol. iii. p. 701. 



GANGRENE OF THE MOUTH. 449 

until the whole face and occasionally the neck are swollen. An excess 
of saliva, often bloody or of a bluish color and of a fetid smell, dribbles 
from the mouth. Mastication is difficult if not impossible, while the 
voice becomes indistinct and speaking difficult. The external sloughing 
goes on extending, while the parts beneath become so rapidly affected, 
that in a few days, the cheek, a part of the lips and the eyelids are re- 
duced to a gangrenous highly fetid pulp ; and there is then a lateral 
opening into the mouth. The teeth, which may be observed through the 
opening, become loose or fall out after the destruction of thj gum ; and 
the adjacent portions of bone become to a greater or less extent ex- 
posed and destroyed. The whole neighbourhood of the gangrenous spot 
has a sodden, livid appearance. In this destructive process, which is 
almost always limited to one side of the face, and which extends much 
more widely on the inner surface of the cheek and in the cavity of the 
mouth than externally, there is a perfect absence of pain or at most 
a dull sensitiveness. In the rare cases in which the gangrene is arrested, 
there is formed an inflammatory (hyperaemic) line of demarcation, sup- 
puration commences in the circumference, and the gangrenous spot 
becomes converted into an ulcer, which gradually assumes a clean and 
healthy appearance, and after cicatrizing for some months, becomes 
healed. When there has been great destruction of tissue, cicatrization 
is always attended with considerable disfigurement, and the pre-existence 
of gangrene of the mouth may be recognized through life by the ugly, 
strongly-contracted cicatrix, puckering the eyelid, the ear or the neck, 
uncovering the eye and distorting the mouth, like the scars left on the 
face after deep burns. 

"The second form appears to be incomparably the more frequent of the 
two. It is however less strongly marked, and owing to its greater affi- 
nity with other affections and a deficiency in correct observation, there 
is much discrepancy in what has been written on it. It runs a slower 
course than the former, and does not so frequently break out with sud- 
denness during convalescence from acute diseases. Instead of the gan- 
grenous destruction with which the first form commences, we here have 
pseudo-membranes of unhealthy appearance on the inner surface of the 
cheek, and ulcers either there or on the outside of the cheek and at the 
corners of the mouth. They either gradually or at once assume a very 
unhealthy character, emit a powerful and fetid odor, and become co- 
vered with sloughs or viscid masses, while the neighboring parts become 
livid and oedematous and the destructive process affects the deeper tis- 
sues. From this stage its further progress is similar to that of the first 
form, excepting, indeed, that the gangrene does not usually extend with 
the same extraordinary rapidity." 1 

641. In the severe form, the disease always commences in the mu- 
cous membrane, preceded by stomatitis, aphthse, or ulceration of the 
gums, lips, or inside of the cheeks, and occasionally with slight oedema. 
This state may persist for several days, or gangrene may set in the 
first day. Then the bottom of the ulcer becomes covered with a layer 
of gray matter evidently gangrenous, and the subjacent tissues are swol- 

1 British and Foreign Med.-Chir. Review, July, 1850, p. 52. 

29 



450 GANGRENE OP THE MOUTH. 

len and hard. When this tumefaction takes place in the cheek, it may 
be felt like a kernel, and the skin outside is tense, shining, and white 
in the centre. 

From this moment the ulcerations extend rapidly; at first of a gray- 
ish color, they shortly become brown and black, covered with " putri- 
lage," of a fetid odor, and bleeding when touched. The edges are 
sometimes regular, sometimes irregular, and raised or level, according 
to the progress of the ulceration, which in a few hours changes their 
appearance. The portions of the mucous membrane of the mouth in 
contact with the gangrenous spots become likewise affected, and run the 
same destructive course. In all directions the disease extends fearfully, 
laying bare and destroying the bones. 

In a short time a livid spot is perceived in the cheek, in the centre 
of the kernel just mentioned ; this spot is surrounded by an inflamed 
base, and is soon perforated by ulceration, which from thence spreads 
rapidly, and in some cases destroys the entire cheek. The gums struck 
by gangrene are destroyed, leaving the teeth bare and loose ; the bones 
of the jaws are affected with necrosis, and exfoliate if life be sufficiently 
prolonged. " The parts," says Mr. Dease, " were continually soaked 
in a cold, putrid, offensive ichor, until often the whole side of the face 
was eat away, particularly the lips, so that the jaw-bone and inside of 
the mouth were exposed to view." "In this situation I have known 
children to live until the entire jaw-bone had fallen down on the breast, 
and the whole side of the face become a mass of putrefaction." 1 

642. As already stated, the primary disease of the mouth is inflam- 
mation and ulceration, upon which gangrene supervenes, and the early 
symptoms are those I mentioned when describing that form of disease. 
The superaddition of gangrene appears in some cases to give rise to but 
little constitutional disturbance, and the child presents^the same general 
aspect as formerly. 

" Premonitory symptoms," M. Wunderlich remarks, " are only 
observed when the affection appears as gangrene and is developed in 
the advanced stage of improvement or convalescence of a pre-existing 
disease (measles, &c), for when there is pseudo-membranous or ulcer- 
ative stomatitis, the gangrenous mortification is only announced by a 
gradual exacerbation of the symptoms, or at most by a shivering, an 
increased appearance of collapse, hemorrhage, &c. When the gan- 
grene supervenes at the height of some other disease, these premonitory 
symptoms are rarely observed. It even frequently happens that when 
the earlier disease has abated to a very great degree and convalescence 
is considerably advanced, this fatal secondary affection will manifest 
itself unannounced by any premonitory symptoms, commencing unex- 
pectedly and suddenly by local swelling. The premonitory symptoms 
when they occur in these cases are not very severe, as for instance, 
lassitude, irritability, loss of appetite, disordered digestion, rigors, 
slight fever, and a somewhat suffering and collapsed appearance." 

In other cases the child, already weakened by previous disease, is 
cross, feverish, and restless, with a quick pulse and hot skin, suffering 

1 Observations on Midwifery, &c, p. 126. 



GANGRENE OF THE MOUTH. 451 

much pain from the mouth until the gangrene is completely established. 
Then the fever seems to subside, for although the pulse remains very 
quick, the skin is cooler, the restlessness diminished, and the aspect 
more calm. The face is of a dull pale color, and has, if I may so speak, 
a dead look about it. The eyelids are not unfrequently swollen, the 
nares incrusted, and the alse nasi dilated in respiration. The lips are 
swollen, and frequently exhibit their share in the mischief going on. 
Altogether the face has a singularly depressed and sorrowful, though 
tranquil, expression. 

The saliva is secreted abundantly, and escapes from the mouth, owing 
to the pain and difficulty of closing the mouth. At first it is the 
ordinary secretion in excess, and perhaps tinged with blood, but after- 
wards it becomes brown or black, mixed with gangrenous detritus. 

The breath is extremely offensive from the beginning, but when gan- 
grene is established both the saliva and breath exhibit the characteristic 
fetid odor. 

The tongue is moist, sometimes yellowish or loaded, and occasionally 
exhibiting the color of the gangrenous spots. The thirst is intense, 
vomiting rarely occurs, and the appetite is not so completely destroyed 
as we might expect ; in fact, when it does fail, it seems rather owing 
to the complications than to the disease of the mouth. The bowels are 
almost always deranged ; diarrhoea is generally present ; sometimes 
griping, with watery stools of a greenish or yellowish color. In a con- 
siderable number of cases the intestinal disorder seems to have preceded 
the gangrene, and to have constituted the primary affection. 

The strength of the child is greatly reduced ; it is emaciated^ weak, 
and helpless. 

643. It has already been stated that gangrene may attack the ulcers 
on the first day; more generally, however, we find it set in from the 
third to the sixth day, and from that time the disease spreads, until, 
after more or less destruction of the tissues, it proves fatal at a period 
varying from five to eighteen days. During this time nothing can be 
conceived more distressing than the condition of the poor child, or more 
heart-rending than its appearance. 

As may be supposed, the great majority of cases terminate fatally, 
but some few cases do recover, mainly those in whom the disease is 
primary, the constitution good, and which remain free from complica- 
tions. 

The improvement may take place before the gangrene has spread 
deeply, and then the mortified portion is cast off, leaving a grayish but 
more healthy ulcer ; the swelling of the surrounding parts diminishes, 
and the constitutional symptoms improve. At a later period, should a 
favorable change occur, the entire gangrenous portion, both the mucous 
membrane and the cutaneous eschar, will be thrown off, leaving a 
granulating surface with healthy suppuration ; the dead bone will 
exfoliate, and the wound gradually fill up and contract. 

Some writers have stated that the form of cancrum oris which com- 
mences externally on the cheek is more under the control of remedies 
than the other forms ; and Dr. Condie considers that the disease is less 
frequent in America than in Europe, and more manageable. 



452 GANGRENE OF THE MOUTH. 

644. A peculiar form of gangrene occurs from the use or abuse of 
mercury, but it is of importance to know that it may arise from a very 
small quantity. Dr. Stokes has mentioned to me one case in which gr. 
iss of calomel, and in another 7 grs. had been taken, and in a third 3j of 
ung. hyd. had been rubbed in, and all had the disease severely. It 
commences by a livid tumor at the angle of the mouth or behind it, 
which increases, ulcerates, and eats away the cheek and even part of 
the eyelids. The gums are dry and hard, and there is no salivation. 
It may occur at any age, but Dr. Stokes has seen it chiefly in young 
girls of 10 or 12 years. 

The disease may be primary or secondary, as I have said, but it 
is not always easy to decide whether the complications have preceded 
the disease or followed it, so little attention has been paid to them 
comparatively. 

We know that intestinal disorder is a frequent concomitant ; it will 
certainly arise in the course of the disease, but it appears probable that 
in some cases the gangrene itself is rather a complication symptomatic 
of the state of the gastro-intestinal mucous membrane. 

Another very frequent and very important complication is pneumo- 
nia ; it occurred in eighteen out of twenty of Rilliet and Barthez's 
cases, and will require our most careful attention if we hope for success 
in our treatment. Whether primary or secondary is comparatively of 
little consequence; it is in itself so serious that it must necessarily 
exercise a predominant influence both upon the course of the disease 
and of the treatment, for if the gangrene were cured the patient would 
incur nearly equal risk from the pneumonia in his exhausted condi- 
tion. 

645. Pathology. — MM. Rilliet and Barthez have given a minute 
analysis of the pathological changes in the different structures, effected 
by the gangrene, drawn from the post-mortem examinations of twenty- 
one cases they witnessed. I shall venture to give a short abstract of 
their record. 1 

After death, the portions of the skin surrounding the gangrene rapidly 
putrefy, and the cheek or the lip is swollen, purplish or greenish, tense 
and shining, hard to the touch, and exhibiting a profound circumscribed 
tumefaction. At the most prominent point we find an eschar, either 
well-defined, round, or oval, and of a moderate size ; or it may be large 
and irregular, extending in different directions towards the nose, eyes, 
and ears, even in some cases occupying nearly the entire face. In the 
latter case the tumefaction is less, and not circumscribed. The depth 
of the eschar varies. 

The mucous membrane, was always affected, sometimes in a limited 
and regular manner, and sometimes irregular, and more extensively. 
The surface was reduced to a semifluid " putrilage," of a gray, brown, 
or black color, removable with the scalpel, and beneath which loose 
shreds of the mucous membrane were perceived. The gums shared in 
the destruction. When the gums were thus destroyed the bones were 
exposed and became black, sometimes affected by necrosis, and exfo- 

1 ' Mai. des Eufans, vol. ii. p. 129, et seq. 



GANGRENE OF THE MOUTH. 453 

liated. This destruction was commensurate with the extent of the gan- 
grene of the mucous membrane. The teeth, denuded and deprived of 
their support, became loose, and were easily detached, often falling out 
of themselves. 

The intermediate tissues were congested, and participated more or 
less in the gangrenous affection. In the milder cases, the adipose 
tissue was infiltrated with serosity, as were also the muscles ; and such 
of these parts as were not actually touched by the gangrene were dis- 
tinctly recognizable. But as the disease advances, or in more severe 
cases, mortification attacks these tissues, especially those nearest the 
mucous membrane, so that the brown putrefied layer is of considerable 
thickness (five to eight millimetres), beneath which we find the adipose 
tissue, and the muscles, infiltrated with serous fluid, losing their dis- 
tinctive organization, and becoming homogeneous, whilst nearer the 
skin there is a layer of cellular tissue, hardened and infiltrated, but not 
mortified. It was rare to find the entire thickness of the cheek affected 
by gangrene. 

646. The condition of the vessels and nerves has always appeared 
doubtful. In one case, examined by M. Billard, he found " nothing 
remarkable." M. Taupin states that he often sought for them, but 
always found them confounded with other tissues, and impossible to 
distinguish from the softened gangrenous mass. 1 

MM. Rilliet and Barthez give the following results of their investiga- 
tion : " In six cases we made a long and minute dissection, and we 
found that when the vessels passed into a portion of tissue, infiltrated, 
but not affected with gangrene, they were perfectly healthy, permeable, 
and their coats scarcely thickened; that when they touched upon a gan- 
grenous part, they were still permeable, but their parietes were thickened, 
and had somewhat the aspect of the gangrenous portion. Lastly, when 
they traversed a gangrenous portion, it was still possible to trace them 
through it, but that the entire extent of the vessel, as it traversed the 
mortified part, was closed from one side to the other, either by a small 
clot at either extremity, or by a larger one filling it throughout." Thus 
the artery was completely obliterated in three cases, and in as many 
the vein was filled with "liquid putrilage." The coats of both were 
thicker and softer than natural. 

Once only the nerves were examined : externally they appeared like 
the surrounding tissue ; their neurilemma was gangrenous, but the pulp 
was sound in color and consistence, and appeared to have resisted the 
gangrene. 

The following details show the comparative frequency of the seat of 
the disease in twenty-nine cases : — 

The left cheek (externally or internally) was affected in . . .11 cases. 

The right cheek 10 " 

The lower lip ........... 4 " 

The lower lip and right cheek ........ 1 case. 

The upper lip and right cheek ........ 1 " 

The left cheek, the angle of reflection of the mucous membrane, and right 

cheek ............ 1 " 

The lower lip, extending to both cheeks and upper lip, on both sides . 1 " 



1 Journal des Connois. Med.-Chirurg., April, 1830, p. 140. 



454 



GANGRENE OF THE MOUTH. 



647. So much for the condition of the parts involved in the gangrene ; 
but the post-mortem examination revealed other lesions connected with 
this disease, either as primary or secondary complications, and which 
are of vital importance. The principal coincident disease was pneumo- 
nia, and the following summary exhibits the character and seat of this 
disease, and of the gangrene, in the same cases : — 

f Of these, gangrene of the right cheek 



Out of 20 cases there was found double 
lobular pneumonia in . 



Double gangrene, but especially of the 

left cheek, in .... 

Gangrene of the lower lip, in . 
Gangrene of the lower lip and right cheek 



Gangrene of left cheek in 
Gangrene of lower lip in 



Double lobular pneumonia, especially on 
the right side (with carnification in 2 
cases) in 5 

Double lobular pneumonia, especially on f Gangrene of right cheek in 

6 \ Gangrene of left cheek in 

1 Gangrene of upper and lower lip in 

1 Gangrene of left cheek in 
1 Gangrene of right cheek in 
« ( Gangrene of right cheek in 
\ Gangrene of left cheek 1 in " 



the left side, in 

Lobar pneumonia of right lung in 

Lobar pneumonia of left lung in 
Carnification of left lung in 

No pneumonia in 



Thus pneumonia (lobular or lobar) existed in eighteen out of twenty 
cases, and occasionally, though rarely, of the same side as the gangrene. 
This accords with the experience of MM. Baudelocque and Taupin. 

In eight of these eighteen cases the pneumonia was secondary, having 
supervened in the course of the gangrene. 

Other lesions, however, were discovered ; as for example : — 

Entero-colitis, or softening of the intestine, in 

Tubercles 

Gangrene of the lung . . 3 ) . 
Gangrene of the pharynx 1 / 

Pleurisy ....... 

Pneumothorax ...... 

Peritonitis 

Pharyngitis 

Nephritis ....... 

Infiltration of the pia mater .... 

Hemorrhage into the arachnoid 

Rachitism 



.4 


cases. 


9 


" 


4 


" 


1 


case. 


1 


" 


1 


" 


1 


" 


1 


" 


2 


cases. 


1 


case. 


2 


cases. 



At first sight it might be supposed that the gangrene resulted from the 
obliteration of the artery ; but this is not borne out by the fact that, so 
long as the mucous membrane is alone affected, the vessel is quite pervi- 
ous ; its obliteration must, therefore, be the effect, not the cause, of the 
gangrene. 

Dr. Condie states that, in the examinations he made, " the principal 
organs in which morbid appearances were present were the stomach, 
intestines, and liver. In all the cases the two former presented the 
indications of inflammation of a more or less chronic character; the 
latter appeared to be affected with hyperemia rather than any struc- 



1 Mai. des Enfans, vol. ii. p. 135. 



GANGRENE OF THE MOUTH. , 455 

tural change. In the majority of cases the mesenteric glands were 
greatly enlarged." 

"In the examination made at the Children's Asylum between June 
1, 1827, and January 1,1830, the morbid appearances exhibited were — 
enlargement and hardening of the mesenteric glands ; a scrofulous con- 
dition of the glands of the neck ; and, in some instances, tubercles of 
the lungs. In general the whole substance of the lung was thickly 
studded with tubercles in various stages of inflammation and suppura- 
tion. The condition of the gastro-intestinal mucous membrane is not 
recorded." 1 

In all the cases examined by Dr. Duncan, he found " either decided 
ulceration of the intestinal mucous membrane, or enlargement and in- 
creased development of the follicular glands. In one case the whole 
colon was an immense sheet of minute, circular, and deep ulcers ; while 
the portion of mucous membrane which intervened was of a bright crim- 
son hue." 2 

648. Causes. — Cancrum oris is almost confined to infancy and early 
childhood. Of twenty-nine cases recorded by Rilliet and Barthez, nine- 
teen were from two to five years old, and the remainder from six to 
fifteen. Of Dr. West's six cases, two were between two and three years 
old; one, three ; one between four and five ; one at six and a quarter ; 
and one at eight years old. It does not appear, however, as was thought 
by Dr. M. Hall, to affect female more than male children. 

As might be expected, we meet the disease most frequently among 
the poor, and for obvious reasons. Their children are badly nourished, 
living in foul air and crowded rooms, surrounded by and participating 
in all kinds of uncleanness. Add to these exciting causes a delicate 
constitution and lymphatic temperament, and we seem to have all the 
elements for the production of the complaint. 

Probably for the same reasons it appears endemic in crowded hospi- 
tals for children, as, for instance, in the Children's Hospital at Philadel- 
phia, where, out of 240 children, seventy were at one time affected with 
the disease; and in other hospitals also. 

Certain localities, likewise, seem peculiarly favorable to it. It is said 
to prevail on the coasts of Holland, Sweden, and Denmark. 

According to the testimony of Thomassen and Thyssen, it prevailed 
epidemically in the Netherlands, as a consequence of gastric fever; and 
also, in 1838, in the Philadelphia Almshouse. 

I believe that few if any authors maintain that gangrene of the mouth 
is contagious, although they prudently advise the separation of the 
healthy from those who are so affected. 

649. We have already noticed certain complications of the disease, 
which may be primary or secondary ; we must, however, inquire a little 
further, as to those diseases in the course of which cancrum oris has 
been found to occur most frequently. This point is one of great im- 
portance, because in the majority of cases it is a secondary disease, in 
some solely dependent upon another preceding it, or upon the state of 
the constitution induced by the latter. 

1 Diseases of Children, p. 168. 2 Dublin Journal, vol. xxviii. p. 18. 



456 GANGRENE OF THE MOUTH. 

M. Baron observes that "it is never a primary affection, but appears 
in children enfeebled by previous disease." 1 

Mr. Dease remarks that, in all the cases he had seen, the children 
"had a pale, bloated, sickly look, large belly," &c. 

Dr. Huxham, in his report for 1745, mentions, " I have more than 
once during this month witnessed a mortification of the mouth and 
fauces; and, besides, a caries of the cheek and os vomeris, which occa- 
sioned a very painful kind of death, and that, too, after measles." 

Dr. Willan refers to a gangrenous eschar of the cheek occurring in a 
case of scarlatina. Dr. Marshall Hall states that " in all the cases 
which have come to his knowledge, this affection had been preceded by 
fever, acute disorder of the digestive organs, inflammation of the lungs, 
variola, rubeola, or scarlatina. This affection would, therefore, appear 
to be in some measure the consequence of the exhaustion, debility, or 
irritation induced by previous disease." 2 

Dr. Cuming advances a similar opinion : " In every instance of this 
affection that I have met with, the constitution had been much debili- 
tated by the existence of previous and long-subsisting disease. In two 
cases that fell under my observation, the disease occurred as a sequela 
of measles; in another, in the advanced stage of dysentery; in a fourth, 
upon the termination of infantile remittent fever ; but it is more gene- 
rally observed at the close of the exanthemata than at that of any other 
of the acute affections to which children are liable." 3 

In M. Poupail's seventy-two cases, the affection followed an attack of 
intermittent or remittent fever ; in nine of Dr. Jackson's cases, it accom- 
panied or followed an attack of bilious or remittent fever. 

MM. Killiet and Barthez agree completely with the opinion of M. 
Baron already quoted : " The disease, in the course of which we have 
most frequently known gangrene of the mouth to occur, is measles. We 
have occasionally observed it in scarlatina, smallpox, and pneumonia. 
We have also known it follow intestinal affections, hooping-cough, scro- 
fula, &c." And they give the following summary of the primary dis- 
eases on which gangrene supervened : — 

On measles in ....... 12 cases. 

Smallpox and measles .... 1 case. 

Scarlatina . . . . . . 1 " 

Scarlatina and smallpox .... 1 " 

(Supposed) cholera ..... 1 " 

Pneumonia, primary and secondary . . 2 cases. 

Pertussis, with or without complication . 3 " 

Enteritis (chronic) and complications . . 1 case. 

Peritonitis and softening of the intestines . 1 " 

Scrofula . . . . . . . . 1 " 

Intermittent fever , . . . . 1 " 

Enteritis (acute) ..... 1 " 

Gibbosity, &c 1 " 

General tubercularization .... 1 " 

In Dr. Duncan's cases, the primary disease appears to have been 
generally an affection of the intestinal canal, although several of the 
cases occurred after measles." 

1 Bull, dela Faculte de Med., 1816, vol. v. p. 158. 

2 Edin. Med. & Surg. Journal, vol. xv. p. 548. 

3 Dublin Hospital Reports, vol. iv. p. 282. 



GANGRENE OP THE MOUTH. 457 

Dr. Geo. Kennedy mentions that it occurred in the course of malig- 
nant typhus fever. 1 

"Of the six cases which I have observed," says Dr. West, " and three 
of which I examined after death, two succeeded to typhus fever, two 
to measles, one came on in a child whose health had been completely 
broken down by ague, and one supervened in a tuberculous child, who 
had been affected for many weeks with ulcerative stomatitis in a severe 
form." 2 

We have already seen that in ten cases out of eighteen the pneumo- 
nia preceded the gangrene, so that the latter disease may sometimes be 
primary and sometimes secondary to the pulmonary affection. 

Nor can we, I think, doubt that there may be an intimate relation 
between scrofulous tubercle of the lungs and cancrum oris. 

Thus we find that the diseases which are most frequently attended 
by gangrene of the mouth are eruptive fevers, as measles, scarlatina, 
smallpox, &c, intermittent and remittent fever, pneumonia, disorders 
of the intestinal canal, tubercles, and scrofula ; while, on the other 
hand, pneumonia and entero-colitis are those which most frequently 
supervene in the course of cancrum oris. 

By several writers, we find the resemblance between gangrene of the 
mouth and mercurial ulceration pointed out; and it has been suggested 
by Bretonneau, Hueter, and others, that true gangrene may follow the 
excessive use of mercury when the mouth is inflamed. 

650. Diagnosis. — The only disease with which cancrum oris is likely 
to be confounded is the one last described, viz: ulcerated sore mouth. 
Both commence by ulceration, and in both we find salivation and a fetid 
odor; but in gangrene the ulcer is covered by a putrid layer, which soon 
becomes dark-colored; the ulceration extends more rapidly and further, 
there is more swelling, often an eschar on the lips or cheek, denudation 
of the teeth and jaw, and ultimately perforation and destruction of the 
cheek. In ulcerated sore mouth, none of these latter characteristics 
occur. 

651. Prognosis. — The prognosis is exceedingly unfavorable. Very 
few cases, indeed, recover; and even when the gangrene appears 
checked, the child has to contend against very serious complications. 
Twenty out of twenty-one of Rilliet and Barthez's cases died, and five 
out of six of Dr. West's. Still, as some have recovered, it is always our 
duty to use every remedy against the local disease without overlooking 
any primary or secondary affection which may exist. 

652. Treatment. — There are four indications to be fulfilled in our 
treatment of the disease: 1. To limit the gangrene, change the character 
of the surface, and remove the fetor of the discharges ; 2. To invigorate 
the constitution of the patient; 3. To favor the separation of the eschar; 
and 4. To remedy the complications, either primary or secondary. 

653. The first indication is most likely to be attained by the applica- 
tion of powerful caustics ; weak ones are of no use. Moreover, merely 
to touch the gangrenous surface will have no effect; to succeed, the 

1 Med. Report of Cork Hosp. for 1837-38, p. 25. 

2 Diseases of Infancy and Childhood, p. 356. 



458 GANGRENE OF THE MOUTH. 

caustic must reach the healthy tissue. Therefore the layer of gangre- 
nous matter must first be removed, or if the situation permit, the gan- 
grenous surface may be cut away, and then the caustic applied carefully 
and liberally once or twice a day. 

Various caustics have been tried, and some with success. Klatoch 
cured one case with pyroligneous acid ; Hueter with acetic acid ; Con- 
stant by the acid nitrate of mercury ; Baron by the actual cautery ; 
and Rilliet and Barthez by nitrate of silver and chloride of lime. 

M. Baron advises that muriatic acid be applied to the gangrenous 
spots in the mucous membrane at the commencement, and that, when 
the external eschar falls, we should apply the actual cautery ; or, what 
is still better, that the eschar should be incised crucially, and then the 
cautery applied. Successful cases thus treated have recently been pub- 
lished by an American writer, Mr. Obree. 

Sulphuric acid has been successful in the hands of Bruineman and 
Courcelles. Mr. Dease speaks highly of the spirit of sea salt (muriatic 
acid), which was used with benefit by Van Swieten previously. " I 
began," he says, " at first to give it in decoction of bark or infusion of 
chamomile flowers, but I could not get children to take it for a continu- 
ance, or in such manner as to give it a fair trial. I therefore gave it 
in an infusion of red roses, which was strongly acidulated with it ; this 
they took without reluctance. At the same time I had the gangrene 
frequently washed with a decoction of chamomile acidulated with the 
spirit of sea salt ; and when the gangrene was considerable and the 
discharge large, dashing the parts with the decoction, by means of a 
syringe, will more effectually wash away the sanies. After this was 
done, I ordered it to be dressed with the honey of roses and spirit of 
sea salt, and over all the carrot poultice to be applied. The child, at 
the same time, should be well supplied with broth, jelly, &c, and 
allowed wine liberally ; good claret will answer best." 1 

Mr. Cooper prefers the strong nitric acid, with the internal exhibi- 
tion of sulphate of quinine and dilute sulphuric acid. 

Mr. Pearson extracted the diseased teeth and some pieces of bone, 
and directed a milk and vegetable diet, with bark, sarsaparilla, and 
elm bark. Locally he preferred the dilute mineral acids, burned alum, 
decoction of bark with sulphate of zinc, tincture of myrrh, &c. In 
addition to the stronger caustics, or in the intervals of using them, M. 
Baron recommends external and internal applications of camphor and 
quinine. 

M. Billard advises frictions, either dry or aromatic, when the oedema 
appears ; and as soon as the kernel is felt, the use of ammoniacal lini- 
ment, or a lotion of the hydrochlorate of ammonia. 

Richter and Rey derived benefit from the use of the chloride of the 
oxide of sodium. Dr. Conclie found a strong solution of copper or zinc, 
applied twice a day, very beneficial ; and in the Children's Hospital, 
Philadelphia, nitrate of silver was the only local remedy employed, and 
the majority recovered. Creasote was very useful in the Philadelphia 

1 Observations on Midwifery, &c, p. 128- 



GANGRENE OF THE MOUTH. 459 

Almshouse, applied after incisions had first been made through the 
gangrenous sloughs. 

After each application of the caustic for the purpose of separating 
the sloughs, the chloride of lime may be applied in order to destroy the 
odor, and it also acts as a stimulant. 

The mouth should be syringed freely and frequently, and the parts 
kept dry and clean. When an eschar appears, a conical incision should 
be made, and the. caustic applied and repeated every day until after the 
eschar separates. Rilliet and Barthez advise that the incision should 
also be filled with quinine. 

I need not say that if there be carious teeth or loose portions of 
bone, they should be removed, as they will keep up an unfavorable 
irritation. 

654. For the purpose of invigorating the constitution, it will be 
necessary to administer tonics as liberally as the condition of the di- 
gestive system will admit. 

Bark may be given in form of infusion, decoction, or syrup, or we 
may prefer the sulphate of quinine from its smaller bulk ; beginning 
with half a grain, we may increase it to two or three grains three times 
a day. 

Dr. Cuming says : "In a few instances in which the disease had 
made considerable progress, I have known recovery to take place under 
the administration of the sulphate of quinine and carbonate of ammo- 
nia ; but in none of these cases had the ulceration extended so far as 
to involve the outside of the lips and cheeks. I have seen that Mr. 
Dease advises the internal exhibition of muriatic acid ; and whether 
we give mineral or vegetable tonics, they must be assisted by the 
liberal use of wine. We cannot, of course, state the exact amount, but 
there need be no hesitation in giving as much as the constitution of the 
child will bear, according to its age, and with reference to the compli- 
cations. 

Dr. Duncan found great benefit from the hyd. c. creta, with Dover's 
Powder, and, although not at the same time, from acidulated decoction 
of bark, or infusion of calumba with nitric acid. In addition, he 
derived the greatest good from counter-irritation to the abdominal sur- 
face. His principal efforts were naturally directed to the causes of the 
intestinal disease. 1 

The diet should be very nutritious, — broths, jellies, minced meat, 
&c, — just as much and of the kind the child can best take. 

It will be necessary, however, to keep a constant check upon the 
tendency to diarrhoea, by chalk mixture with opium, or opium com- 
bined with the quinine or ammonia ; or a drop of laudanum may be 
given once, twice, or thrice a day in milk. 

The child should be kept in a large, well-warmed, and well-ventilated 
apartment ; but in our anxiety for pure air we must beware of draughts 
of cold, remembering the liability to pneumonia in this disease. 

The most scrupulous cleanliness, both local and general, should be 
observed. 

1 See also Dublin Journal, Nov. 1852, p. 265. 



460 TONSILLITIS. 

I must repeat that the most anxious care and watchfulness of the 
physician should be directed to the complications. Knowing that in- 
flammation of the lungs so frequently occurs (whether primary or 
secondary) in connection with cancrum oris, we ought daily to ascer- 
tain the condition of these organs, that by detecting the earliest incur- 
sion of the disease we may the more effectually apply the remedy. The 
same may be said of entero-colitis, which also complicates this disease. 

For the suitable method of treating these diseases, I must refer the 
reader to the chapters relating to them. 

Dr. Stokes has found the mercurial cancrum oris manageable, if he 
saw the patient within twelve hours from the setting in of the disease. 
He recommends that the patient should be kept sitting up in bed, that 
relays of leeches should be applied to the livid tumor as frequently as 
the strength will admit, and that the strength should be kept up by wine 
and good diet. 

If the tumor be reduced before ulceration occurs, the patient will be 
saved. 



CHAPTER VIII. 

TONSILLITIS. — CYNANCHE TONSILLARIS. — QUINSY. 

655. This disease, which consists of inflammation of those massed 
of mucous follicles called the tonsils or amygdalae, and of the neighbor- 
ing mucous membrane, is sufficiently common in children of all ages 
and constitutions ; and, because it is painful and subject to ocular in- 
vestigation, has been noticed by almost all writers from Hippocrates to 
the present time. 

It is seldom so severe and acute in children as in adults, but is much 
more liable to take on a subacute form, enlarging these organs, continu- 
ing for a considerable period, altering more or less the tone of voice, 
and impeding deglutition, hearing, and occasionally the breathing. 

656. Symptoms. — Generally speaking, the complaint commences with 
the symptoms of a cold ; the child is chilly, creeping to the fire, or ifc 
has regular rigors followed by fever ; it is uneasy, distressed, and cross, 
with a huskiness of voice and a sense of roughness in the throat, which 
is shortly changed for soreness and pain, especially in attempting to 
swallow. 

Sometimes, however, as Dewees has observed, it appears to be a 
purely local affection, without fever or any constitutional disturbance. 

In the other cases, the fever continues to increase for a time; the 
skin is hot and florid, the face flushed and puffed, the pulse rapid and 
full, the tongue loaded and white, with red papillas appearing through 
the white coating. The thirst is great ; but there is great pain and 
difficulty in swallowing fluids especially. 

Upon examining the throat, to which we are led at once by the com- 
plaints of the child, we find one or both tonsils enlarged, of a bright or 



TONSILLITIS. 461 

red color ; the uvula, velum, palate, and pharynx, red, swollen, 
and cedematous, but generally more painful on one side than the other, 
and on the surface we find more or less of thick, viscid, mucous secre- 
tion. In some cases, patches of coagulable lymph may be observed on 
the tonsils, giving the appearance of small sloughs. 

The extent of the swelling varies according to the intensity of the 
attack. In severe cases, the tonsils are so much enlarged that they 
almost close the pharynx, and protrude the swollen uvula forwards ; 
and not only so, but the deeper tissues appear involved, so that the 
neck appears enlarged, and, from the interruption to the circulation, 
gives to the face and neck a flushed or congested look. Beneath the 
angle of the jaw, the tonsil may be felt enlarged, hard, and painful, and 
the carotids are seen beating strongly. 

The child complains of soreness of the throat, and is continually 
attempting to detach and expectorate the viscid mucus. Swallowing 
is very painful, but with soft solids less than with fluids ; more so with 
the saliva than anything else, because of the increased muscular effort 
required, and the consequent pressure upon the inflamed parts. There 
are darting pains from the fauces to the ears, frequently some degree 
of nausea ; and in a few cases, we find respiration impeded ; but this, 
I am convinced, is rare, the rapid and hurried breathing being ordi- 
narily owing to the fever. 

The fever may run very high, and delirium be an attendant upon the 
disease. 

This description, however, is rather of a very severe case than of the 
form ordinarily observed, which is marked by fever, soreness of throat, 
dysphagia, and inflammation of the tonsils, neither extremely distress- 
ing nor very persistent under ordinary management. 

657. After a duration varying from a day to ten days or a fortnight, 
the attack may terminate in either of three ways. 

I. In the great majority of cases it terminates in resolution, by the 
gradual subsidence of the fever, the diminution of the inflammation, and 
the reduction of the swelling ; after which there remains a remarkable 
degree of weakness and lassitude. 

II. In those cases where the inflammation is subacute, or in those 
where the inflammation, at first acute, subsides only to a certain point, 
we have less fever and less suffering, but the disease does not subside so 
frankly as in the others. The fever and distress may disappear, but 
the swelling of the tonsils does not ; they remain enlarged, as it were 
hypertrophied, for a long time, or permanently, in lymphatic or scro- 
fulous children : they feel soft, but of two or three times their natural 
size. There is no pain, but some difficulty in swallowing, and in all cases 
an alteration in the voice, similar to what is popularly called " speaking 
through the nose." 

Children in whom the tonsils are thus left, are very liable to a return 
of the inflammation on catching the slightest cold. 

in. Tonsillitis very commonly terminates in suppuration, though not 
quite so frequently as in adults. After reaching the maximum of in- 
tensity, the inflammation seems to subside, but not the swelling ; there 
is less pain, but the mechanical obstacle to deglutition remains ; the 



462 TONSILLITIS. 

patient is wearied, exhausted, and almost worn out by suffering and want 
of food. At length, the tissues having been thinned, the abscess points 
and breaks, and the patient obtains complete relief. Generally the 
abscess bursts internally, but cases are on record of its opening or being 
opened externally below the angle of the jaw. 

The quantity of matter is never considerable, and in some cases we 
may fail in detecting any, from its being swallowed, and can only satisfy 
ourselves of its escape by the sudden relief of the distress. 

658. Causes. — The ordinary cause of tonsillitis is cold, and we find 
the disease most prevalent in low, damp, and cold situations, and at those 
times and seasons when the weather is most changeable. 

A second attack of the disease is more easily incurred, and excited by 
slighter causes than the first. In some children with enlarged and tender 
tonsils I have observed them affected by atmospheric changes without 
apparently having taken cold. 

659. Diagnosis. — When very severe, the disease has some resem- 
blance to mumps, but in the latter the pain and swelling are chiefly in 
the parotid gland, and extend from the angle of the jaw to the ear, 
and there is no inflammation of the tonsils or redness of the neighbor- 
ing parts. 

660. Treatment. — If we see the child immediately after the com- 
mencement of the attack, it is possible occasionally to cut it short by a 
stimulating gargle, or by strong counter-irritants externally. 

If these fail, or if we are not called sufficiently early, yet if the at- 
tack be mild, it will be easily subdued by gentle antiphlogistic measures. 
A brisk purgative, followed by sudorifics, fomentations, or poultices ; 
warm pediluvia, with low diet for a few days, will generally afford relief. 

When the inflammation is considerable and the fever high, we must 
have recourse to more decided measures. Topical bleeding, either by 
leeches to the neck or scarifying the tonsils, will be .necessary. The 
former, I think, are generally preferable, although Kopp speaks of the 
latter as the most prompt and efficacious remedy we possess. Occa- 
sionally, but rarely, it may be advisable to take blood from the arm in 
older children. After the leeches fall off, or when the bleeding has 
stopped, the most comfortable application is a light warm poultice fre- 
quently renewed. 

Great relief may also be obtained by inhaling the vapor of warm 
water, but this should be always done from the mouth of a jug, and 
never from the spout of a teapot, with children, on account of the 
danger of closing the lips and drawing up the water. 

Internally, after freeing the bowels well, we may give minute doses 
of tartar emetic, not so as to excite vomiting, unless the viscid mucus 
be very troublesome, but just so much as to lower the fever and excite 
the action of the skin. 

Loeffler and other continental physicians speak very highly of the 
hydrochlorate of ammonia in tonsillitis. Dr. Condie states that he has 
derived very great advantage from it. He combines it with ipecacu- 
anha and calomel, so as to give three or four grains of it every three 
hours. 

661. There are two other remedies generally used, but often without 



TONSILLITIS. 463 

sufficient discrimination, and about which opinions have varied ; I mean 
gargles and blisters. 

At the commencement of the attack stimulating gargles may be use- 
ful, but afterwards I quite agree with Dewees that either stimulating or 
astringent gargles are rather injurious until the decline of the disease. 
During its height warm water is the best gargle, or if the viscid mucus 
be very troublesome, we may adopt Eberle's plan of using warm water 
slightly acidulated with vinegar. When the inflammation and fever are 
subsiding, we may use either acid or astringent gargles with benefit, or 
we may try the vapor of vinegar and water, as recommended by Hip- 
pocrates, or other medicated vapors. 

The same rule holds good with regard to blisters. During the in- 
crease and height of the disease, soothing applications externally 
are advisable; liniments, blisters, &c, seem to do harm; but after the 
acute stage has somewhat passed, much benefit will be derived from 
stimulating liniments, mustard and meal poultices, or turpentine. I do 
not like blistering the throat of young children if it can be avoided, as 
the surface is very apt to remain very sore, or perhaps to ulcerate. 

662. When suppuration seems determined upon, we ought to encou- 
rage it by poultices, inhalation of aqueous vapor, gargles of warm 
water, &c. 

If there be much delay before the abscess opens, and if the patient 
be much exhausted, or if the swelling should be so great as to interfere 
with the breathing, it will be better to make an opening with a bistoury, 
taking great care that no movements of the child give rise to mischief. 

Dr. Mason Good mentions that in some cases tracheotomy has been 
found necessary ; but such cases must be very rare indeed. 

The diet should be low until the disease subside, and then the child 
must be nourished by broths, jellies, or meat, according to its age and 
power of swallowing. 

663. Dr. Dewees observes : " As regards the erysipelatous species of 
the disease, the treatment is somewhat different. We rely more on 
topical bleeding and the vesicatory applications, and when aphthae or 
sloughs appear, on stimulating gargles ; and in the event of extreme 
debility supervening, the system is to be supported by bark, wine, the 
carbonate of ammonia, and whatever else enters into the treatment of 
putrid sore throat." 1 

When the tonsils remain permanently enlarged, we must make some 
efforts to reduce them, not only on account of the liability to repeated 
attacks of inflammation, but because they involve a disagreeable change 
of voice and discomfort in swallowing. Dr. Condie advises the repeated 
application of nitrate of silver ; others, repeated small blisters exter- 
nally ; others, their removal by operation. Professor Hess, of Copen- 
hagen, states that he has employed compression, by means of the index 
finger applied to the indurated tonsil, with success. This to be repeated 
three or four times a day ; and when the gland becomes softer, and ab- 
sorption commences, gargles may be used. 2 Each of these plans may 
succeed, and we may try any or all of them, but I would also suggest 

1 Diseases of Children, p. 451. 2 Banking's Abstract, vol. ii. p. 192. 



464 PAROTITIS. 

that the internal application of the caustic tincture of iodine, as well as 
the external use of the ointment, should have a fair trial previous to 
any operation. I have seen it very successful in several cases. 

As to the removal of the tonsils, I should be strongly opposed to such 
an operation during childhood, as it is by no means generally successful, 
and may leave consequences more troublesome than the disease. I do 
not, therefore, think it necessary to occupy the reader's time by a de- 
scription of the mode of operating. 

As to the prophylactic treatment, it is desirable, of course, that 
children liable to this affection should avoid all occasions of cold, and 
on the first sensation of sore throat should be treated with external 
stimulating applications to the throat, such as mustard poultices, tur- 
pentine, compound camphor liniment, &c, and purgatives. 



CHAPTER IX. 

PAROTITIS. — CYNANCHB PAROTIDEA. — MUMPS. 

664. This is a very common disease, although it rarely attacks very 
young children, seldom those under five or six years of age, and, ac- 
cording to Dr. West, more frequently boys than girls ; but this does 
not accord with my experience. 

It consists of inflammation of the parotid gland of one or both sides, 
occurring together or separately ; and during certain seasons it prevails 
epidemically, as in Dublin and other parts of Ireland this last winter. 

Dr. Stewart seems to regard it as one of those diseases which a child 
must generally have once in its life, but which rarely occurs a second 
time. 

665. Symptoms. — In the majority of cases the child seems suffering 
under a feverish cold for a few days before the local symptoms display 
themselves ; it is chilly, uncomfortable, cross, and complains of aching 
of the limbs, followed by feverish heat of skin, quick pulse, thirst, &c, 
and then pain is felt about the angle of one or both jaws, and difficulty 
of opening the mouth to speak or masticate. 

In other cases we have no preliminary feverishness, but the disease 
commences at once by pain or swelling at the angle of the jaw. 

The pain is soon followed by tumefaction behind the angle of the jaw, 
extending upward to the ear, forward a little on the cheek, and down- 
wards to the maxillary gland, involving the parotid gland and the sur- 
rounding cellular tissue. It feels firm, hard, and hot, is painful on 
pressure, but generally speaking the color of the skin is unchanged ; 
in severe cases it becomes slightly red or pink. 

Not only is there irregularity of the two sides of the face thus pro- 
duced, but I have seen the lower jaw temporarily displaced, and pushed 
over towards the sound side. 

There is great pain and difficulty in opening the mouth and in moving 



PAROTITIS. 465 

the jaw, either to masticate or to swallow, although the dysphagia is 
evidently not from sore throat. 

One or both sides of the face may be thus affected, or, after the sub- 
sidence of the one, the opposite may succeed to the swelling; and it is 
from the extraordinary expression of sullenness thus given to the coun- 
tenance that the name "mumps" has been given to the disease. 

666. If the attack be mild, the fever, swelling, and pain, will be 
moderate, and after a few days will subside without the child having 
suffered much distress; but in some of the severe cases the suffering is 
very great; the tumor is very large, hard, and exquisitely tender; the 
skin covering it of a reddish tinge; the difficulty of opening the mouth 
so great that the child can scarcely take food, and even when in its 
mouth, it is almost impossible to swallow it. The fever runs very high, 
the pulse is full and rapid, and the brain is more or less involved, with 
delirium, &c, which have occasionally proved fatal, according to Dr. 
Cullen. 

Moreover, in such cases the swelling extends far beyond the parotid 
glands, and involves not merely the surrounding cellular tissue, but the 
submaxillary glands, and the suffering and distress are very great. Such 
cases are, fortunately, rather uncommon. 

667. A remarkable peculiarity of mumps is the disposition to metas- 
tasis. The pain and swelling of the parotid gland will sometimes 
suddenly subside, and the mammae in girls, or the testes in boys, become 
instantly affected with severe pain, swelling, and tenderness. "In the 
male," says Dr. Dewees, " we once saw the testes prodigiously enlarged; 
much suffering was endured, and great hazard was incurred by the 
change. Violent fever and delirium accompanied this change of seat 
of the disease, and it required a perseverance in very active remedies to 
subdue them." 1 The same was observed by MM. Eilliet and Benguier. 

It has been stated by Dr. Hamilton and others that this metastasis 
to the testes has been followed by the absorption of the gland, so that 
the tunica vaginalis became an empty sac. 

The breasts in female children become very painful, hard, and swollen, 
but it does not appear that they are liable to the same wasting away 
afterwards, nor do they run on to suppuration. 

Again, a similar metastasis may take place, and the brain or its mem- 
branes become the seat of the secondary attack ; and this is more 
frequent, Dr. Stewart thinks, in those cases where no metastasis to the 
testes or mammae takes place. This cerebral metastasis is highly dan- 
gerous. The child is attacked by coma or delirium, and may die in a 
few hours if prompt measures be not taken for its relief. 

Two cases of this kind are recorded by Dr. Harvey Luidsly which 
proved fatal. In one of them there were decided marks of inflamma- 
tion and congestion of the cerebellum, but none in the cerebrum. 2 

668. The dilation of the disease varies much. In some cases the 
swelling, pain, and fever reach their maximum in forty-eight hours, and 
then begin to subside ; in others, not till the fourth or fifth day, and 

1 Diseases of Children, p. 143. 2 Araer. Med. Journ., April 1851, p. 542. 

30 



466 PAROTITIS. 

some are prolonged to ten or twelve days. The disease is lengthened, 
also, in those cases in which the two glands are successively attacked. 

In by far the majority of cases, the attack terminates in resolution, 
after the height is reached ; the fever and pain subside, the swelling 
diminishes, and the tenderness gradually disappears. 

But in some rare cases suppuration takes place, and matter makes its 
way to the surface. 

669. Causes. — Cold from damp clothing, damp beds, &c, seems to 
be the principal cause, where the disease is not epidemic. And in damp, 
marshy situations those attacks seem to be endemic, and owing to the 
same cause. But it prevails, also, epidemically and very extensively 
during damp weather, especially in winter and spring. During the 
spring of 1849 it was very generally epidemic in Dublin and other parts 
of Ireland. I heard of one school in which there were twelve, another 
in which there were sixteen children affected at one time, and there are 
probably few practitioners of this city who had not abundant opportu- 
nities of witnessing different children of the same family attacked to- 
gether or successively. M. Rilliet has published an account of an 
epidemic which prevailed at Geneva from March 1848 to May 1849, 
principally among children between five and fifteen years of age. He 
believes it to be contagious and analogous to eruptive fevers. 

An epidemic also occurred in Montpellier in February, March, April, 
and May 1818, and has been described by M. Ressiguier. 1 Whether 
it really be contagious at the time when it is epidemic, as Dr. Stewart 
and M. Rilliet and others suppose, is a question not so easy of solution 
as might be supposed, because, although children of the same family 
are undoubtedly exposed to the influence of contact, they are also ex- 
posed to exactly the same epidemic causes. 

670. Treatment. — The treatment required by simple cases of paro- 
titis is very slight. We may administer an emetic, or a brisk purga- 
tive, followed by calomel and antimonials in small doses, with fomenta- 
tions or poultices to the tumefied jaw, and these may be sufficient. 

But when the swelling is considerable, the pain great, and the fever 
high, it will be necessary to apply leeches to the part affected, and to 
continue the poultices constantly, fomenting the jaw with hot water or 
decoction of poppy-heads whenever the poultice is renewed. 

The purgative may be repeated occasionally, and the James's Powder, 
with or without the calomel, continued until the inflammation begins to 
subside. Pediluvia at bedtime, or an occasional warm bath, will be found 
very useful. 

When the testicles or mammse are attacked, it will be necessary to 
apply leeches, fomentations, or poultices, according to the amount of 
inflammation. When this metastasis takes place, it has been thought 
advisable by some writers to apply blisters, or irritants of some kind, 
over the original seat of the mischief, for the purpose of bringing back 
the inflammation to the parotid gland. Dewees remarks : " We have 
always blistered the parts immediately over the parotids, and we think 
with decided advantage." Dr. Condie, however, does not believe that 

- 1 Gaz. Med., 1850. Brit, and For. Rev., Oct. 1850. 



PAROTITIS. 467 

any good can result from tins practice, and I am induced to agree with 
him ; at least I have never found it necessary. 

When the brain is attacked, it will be necessary to meet the increased 
danger very promptly and actively, by the usual means of leeching, 
cold lotions, blisters, calomel, and James's powder, with occasional 
purgatives, &c. 

671. During the prevalence of mumps this last winter, I have seen 
a disease which might easily have been mistaken for it, but which is, 
in truth, inflammation of the cellular tissue in the neighborhood of the 
parotid, and which often ends in abscess. It has been noticed by Dr. 
Good as phlegmone parotidsea, and by Mr. James as angina externa. 
In the beginning it is very like parotitis ; there is pain, soreness, and 
swelling near the angle of the jaw, but of one side only ; great difficulty 
in opening the mouth ; pain in mastication ; and febrile excitement ; 
but the tumor is generally below the parotid, more superficial, and the 
skin is more discolored. In some cases the inflammation is deeper 
seated and more extensive, the tumor occupying, as Dr. Condie observes, 
the front of the throat from ear to ear, with oedema of the face occa- 
sionally. Suppuration generally takes place ; the swelling becomes 
more prominent at one part, and paler generally ; softening occurs ; 
fluctuation is felt ; and ultimately the abscess bursts, or is opened, and 
the tumor gradually disappears. 

" Instead of a circumscribed inflammation and suppuration, the 
inflammation is occasionally deep-seated and diffused, and the pus, when 
it forms, is then liable to extend under the angle of the jaw to the 
pharynx, or downwards into the upper part of the thorax, producing 
extensive destruction of the cellular membrane about the neck, and 
great distress to the patient." When suppuration takes place, the 
swelling acquires a doughy feel, and an indistinct fluctuation may be 
perceived at one or more points. The matter is slow in arriving at the 
surface, and in discharging itself externally. In some instances, dis- 
tinct, deep-seated collections of matter form, and the pus, mixing with 
the dead cellular membrane, becomes putrid, and the evolution of gas 
thus produced causes a kind of emphysematous condition of the parts. 
The febrile symptoms now assume a low, typhoid character, the strength 
of the patient is rapidly exhausted, and death very generally ensues ; 
or, if recovery takes place in these extreme cases, an extensive and 
unsightly cicatrix deforms the patient for life." 1 

672. In cases of the simple phlegmonous inflammation, a few leeches 
should be applied to the tumor, followed by poultices, fomentations, 
and a brisk purgative. Dr. Condie recommends a cold lotion after the 
leech-bites have ceased bleeding. The patient must be kept on low 
diet. Whenever suppuration has taken place, and fluctuation can be 
detected, the abscess should be freely opened, and poultices continued 
after the free evacuation of the pus. With a little care, we may 
generally arrange the opening so that no mark shall be visible after- 
wards. 

When the inflammation is diffused, the early stage will demand a 

1 Condie on Diseases of Children, p. 192. 



468 PSEUDO-MEMBRANOUS PHARYNGITIS. 

similar treatment ; but as soon as the swelling acquires a doughy feel, 
especially if there be difficulty of swallowing, impeded respiration, or 
cou^h, it will be advisable to make free incisions into the tumor, and 
then to apply poultices. If the child be much reduced, we must allow 
better diet, and perhaps, in some cases, wine and bark. 



CHAPTER X. 



PSEUDO-MEMBRANOUS PHARYNGITIS. — DIPHTHERITE. — ANGINA PSEUDO- 
MEMBRANOSA. 

673. In a former chapter I described simple or erythematous pha- 
ryngitis, under the name of cynanche tonsillaris, or at least the descrip- 
tion of the one may stand for the other, for any difference between 
them is almost imaginary. 

Now we have to do with a more serious affection, having much more 
complicated relations ; essentially an inflammation of the mucous mem- 
brane of the pharynx, but which is accompanied by a secretion of 
coagulable lymph or false membrane, with or without a breach of the 
mucous surface. 

The disease appears to have prevailed from very early times. Are- 
tseus mentions it as a complication of croup ; P. Forest observed an 
epidemic at Alkmar, in Holland ; it appeared in Spain in the seven- 
teenth century ; at Naples in 1618 ; and about 1686, at Kingston, in 
America. A similar epidemic prevailed in Paris, from 1743 to 1748, 
and has been described by MM. Malouin and Chomel ; in England 
about the same time, and at Cremona. I cannot agree, however, with 
Rilliet and Barthez, that the "putrid sore throat" of Br. Fothergiil 
was diphtherite ; but rather gangrenous pharyngitis. 

We are mainly indebted for our knowledge of the disease to the labors 
of Dr. S, Bard, of New York, 1 M. Bretonneau, of Tours, M. Deslandes, 
and Rilliet and Barthez. 

But it is not merely as an idiopathic or primary disease that this 
diphtheritic affection is to be considered; it forms a very important 
complication of several diseases, particularly the eruptive fevers. We 
must, therefore, examine into its characteristics, both when primary 
and when secondary. 

674. Symptoms. — Primary pseudo-membranous pharyngitis may 
commence very mildly, not unlike common sore throat, with a slight 
febrile excitement, or without any, the appetite and strength being but 
little deranged. Or in some cases the fever may be more intense, with 
general uneasiness, aching of the limbs, thirst, &c. ; and shortly after- 
wards the child will complain of soreness of the throat, increased by 
swallowing, especially if the bulk be small. 

1 Trans, of American Philosophical Society, vol. i. 



PSEUDO-MEMBRANOUS PHARYNGITIS. 469 

In the majority of M. Bretonneau's and Rilliet and Barthez's cases 
there was but little fever, but in a few cases (four altogether) the fever 
was intense. The epidemic character may also modify this peculiarity ; 
thus, in the one described by Dr. Bard and M. Ferrand, 1 there was no 
fever, but in the observations of M. L'Espine 2 it was intense. 

Pain in the pharynx is rarely severe ; it is felt at the beginning 
chiefly, but it does not go on increasing; sometimes it is absent alto- 
gether, and I may say the same of the distress in swallowing. I have 
seen it very considerable, with a sense of heat and local soreness, and 
I have also seen it entirely wanting. This is the experience of M. 
Bretonneau. 3 

" The voice is commonly obscure and nasal, but not hoarse or whisper- 
ing, unless the disease extends into the larynx, in which case the symp- 
toms will be those of croup, already described. Cough sometimes 
exists, but it usually resembles in sound that produced by the action of 
hawking rather than a common cough, and is altogether different from 
the tone of the cough of laryngitis." 4 

For a short time after the commencement of the disease, if we ex- 
amine the throat, we shall discover some redness and swelling of the 
tonsils, but we shall shortly perceive patches of coagulable lymph here 
and there on these organs, of a white or yellowish-white color, more 
rarely gray, with thin edges, and which, coalescing, cover the tonsils, 
palatine vault, and pharynx, with this lardaceous false membrane. Not 
only does it spread gradually over the neighboring parts, but it also in- 
creases in thickness, until the parts affected seem as if covered with 
curd, not evenly, and as if by a continuous membrane, but by patches, 
some large and some small, giving to the surface a lichenoid appearance, 
as M. Bretonneau justly describes it. Occasionally they present the 
aspect of a deep ulcer or fissure. More or less they will be found to 
cover the uvula, the tonsils, and the pharynx. 

Sometimes in the latter situation the layer is semi-transparent, or it 
may be covered with mucus, either of which circumstances may at first 
deceive us as to the existence of the false membrane. 

After the lapse of a few days, the false membrane begins to detach 
itself, not regularly, but here and there, leaving the mucous surface 
smooth and bright red ; or it may become gradually thinner, until it 
entirely disappears, and then, in many cases, it is renewed more or less 
completely, and is again thrown off, until the disease is cured. 

Rilliet and Barthez state that in twenty-one cases the false mem- 
brane occupied the tonsils only in six; the tonsils and some part of the 
velum palati, in four ; the tonsils, the vault of the palate, and the pha- 
rynx, in six ; the tonsils and the pharynx, in five. 

675. The false membranes, and the parts covered by them, sometimes 
present a much more alarming aspect than the one just described. 
They appear as gray, reddish, or blackish shreds, attached to the ton- 
sils or palatine vault ; the soft parts of the fauces appear sphacelated ; 
the vault of the palate, the tonsils, and the mucous membrane of the 

1 Thesis, 1827, p. 8. z Archives Gen. de He'd., 1830, vol. xxiii. p. 521. 

2 De la Diphtherite, p 113, &c. 4 Meigs on Diseases of Children, p. 208. 



470 PSEUDO-MEMBRANOUS PHARYNGITIS. 

pharynx seem detached in part, and there are gray patches, with violet- 
colored edges, resembling gangrenous eschars. The breath becomes 
very fetid, and there is profuse salivation. 1 This form is rare, and 
resembles the putrid sore throat of Fothergill and others, in many 
points. 

676. Four or five days after the appearance of the false membranes, 
we find the submaxillary glands become painful, swollen, and tender, 
especially on that side on which the inflammation is most intense. The 
cellular tissue of the neck may also become affected, and the neck 
increase in volume considerably ; but this seems to be more owing to 
infiltration of serum than to inflammation. When the progress of the 
disease is favorable, the false membranes are thrown off, and not repro- 
duced ; the swelling of the submaxillary gland subsides, the redness of 
the mucous membrane disappears, and in eight or ten days the disease 
is cured. 

Cases may, however, terminate unfavorably by the extension of the 
false membranes to the air-passages, giving rise to croup, &c, or the 
disease may assume a typhoid type, but whether from the poisoning 
caused by the absorption of the putrid secretions, as supposed by M. 
Bourgeois, 2 or not, may be doubtful. 

"In the commencement of the disease the tongue is pointed, red at 
the edges, and covered on its surface with a thin layer of white mucus, 
through which the enlarged and florid papillae protrude. There is an 
increased secretion of saliva, which soon becomes dark-colored, from an 
admixture of blood discharged from the mucous membrane as portions 
of the pseudo-membranous deposit are detached, and of an offensive 
odor, from the vitiated state of the secretions of the throat and 
mouth." 3 

When the attack is severe, there is considerable fever, with heat of 
skin, quick pulse, difficulty and pain in swallowing ; if the disease ex- 
tend upward into the posterior nares, the child cannot breathe through 
the nostrils ; and if into the Eustachian tube, the hearing will be imper- 
fect, or perhaps complete deafness may be produced. 

So far, then, we find primary diphtheritis to be characterized by a 
few and unimportant general symptoms in the majority of cases ; by a 
certain amount of fever, loss of appetite, soreness of throat, and pain 
in swallowing, in others ; and in all, by inflammation of the mucous 
membrane of the pharynx and neighboring parts, with a deposition of 
coagulable lymph, or curdy false membrane. 

677. Secondary diphtheritis exhibits the following modification of 
these symptoms, according to Rilliet and Barthez : "1. It commences 
by vivid and general redness and swelling of the palatopharyngeal 
mucous membrane. 2. After an uncertain time, there appear upon 
the tonsils small whitish or yellow patches, in general thin, superficial, 
and easily detached ; most frequently limited to the tonsils, occasionally 
involving the uvula and palate, and more rarely the pharynx. Ac- 

1 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 291. 

2 Journal Gen. de Med., vol. cix. p. 441. 

3 Condie on Diseases of Children, p. 181. 



PSEUDO-MEMBRANOUS PHARYNGITIS. 471 

cording to authors, we find that the false membranes of secondary 
pharyngitis, and particularly in scarlatina, may assume a gangrenous 
appearance, having a strong resemblance to some already noticed. 3. 
The swelling of the submaxillary gland is the same. 4. The pain, often 
more intense than in the primary form, exhibits the same characteristics. 
5. The fever, always more intense, most generally is dependent upon 
the original disease." 1 

678. Morbid Anatomy. — According to Bretonneau, the false mem- 
branes may sometimes be found on the first day of the disease, gene- 
rally somewhat later. They first appear as whitish or yellowish 
patches on the tonsils, circumscribed and resembling flakes of curd ; 
increasing in number and extent, they coalesce more or less completely. 
They adhere sufficiently firmly to the mucous membrane, vary in thick- 
ness, and increase by additional layers. Occasionally they are mixed 
with blood, and acquire a gray or brown color, which has led to the 
supposition of their being gangrenous. They are in direct contact with 
the mucous membrane, and are not covered by epithelium, according 
to Bretonneau, Rilliet and Barthez. The mucous membrane beneath 
the deposition is more or less injected and red, and often presents spots 
of ecchymosis. Rilliet and Barthez and Guersent conceive that in some 
cases there is loss of substance from ulceration ; such cases, however, 
are very rare. The submaxillary glands are enlarged, but rarely sup- 
purate ; their tissue is tender, homogeneous, and of a whitish-red color at 
an early period, and resembling the structure of the kidney at a more 
advanced stage. 

679. In secondary diphtheritis, we find the mucous membrane of a 
bright red, rough and unequal, much thickened and softened ; the ton- 
sils enlarged, soft, and irregular; not unfrequently, also, we find a 
breach of surface : ulcerations of various forms extend in different direc- 
tions, deep or superficial, with level or raised edges, and healthy or 
unhealthy surfaces. 

False membranes may be generally observed at different points ; 
seldom over the entire fauces. They are generally thin, soft, and 
fragile, of a whitish, grayish, or yellowish color, and mixed with puru- 
lent matter. Sometimes the false membranes occupy the superior or 
inferior part of the pharynx, the intermediate portion being intensely 
inflamed, and covered with purulent matter. 

The submaxillary glands are enlarged, red, and soft. 

Considerable difference of opinion prevails as to the pathological 
character of the disease. Bretonneau, Guersent, and others, maintain 
that it is a specific inflammation ; Broussais and Emmangard, that it is 
a gastro-enteritis; Joly, that it is a hemorrhagic inflammation, in which 
colorless fibrine is exuded upon the inflamed surface ; Naumann attri- 
butes it to a change in the condition of the blood, in consequence of 
which the albuminous portion is separated and exuded ; and Andral 
regards the disease as hypersemia of the fauces, with exudation of coagu- 
lable lymph. 

1 Mai. des Enfans, vol. i. p. 295. 



472 PSEUDO-MEMBRANOUS PHARYNGITIS. 

The latter is, no doubt, a true expression of the fact ; hut neither 
that nor any of these opinions deserve the character of an explanation 
of the nature of the disease. 

For fuller details, I must refer the reader to M. Bretonneau's elabo- 
rate work. 1 

680. Complications. — These are of two kinds, those which consist of 
an extension of the same disease, and those which result from the gene- 
ral condition of the patient. 

I. The secretion of false membranes may not be limited to the pha- 
rynx, but may extend itself to the nasal apertures, or into the larynx, 
trachea, and bronchi. This coincidence and succession is very remark- 
able in some epidemics. M. Bretonneau states that the angina or co- 
ryza appears first, then the laryngitis, then bronchitis. It is very rare 
that this order is reversed, and still more rarely does the disease appear 
in different parts simultaneously. It is especially in an epidemic that 
these complications occur. 

I am not prepared to speak positively as to the extension of the 
diphtherite to the stomach and intestinal canal, but I confess I think it 
extremely probable; for we find shreds of what looks like the false 
membrane voided by stool in cases of this disease; and most, I suppose, 
have seen the diphtheritic deposit around the anus. 

ii. The disease may also attack remote parts of the body, particu- 
larly parts covered by mucous membrane, or from which the cuticle 
has been removed by a blister, according to M. Trousseau. Thus, the 
pseudo-membranous secretion may be observed upon the lips, alse nasi, 
the concha, the external meatus behind the ear, in the groin, on the 
nipples, &c. 

in. Another elass of complications, dependent upon some peculiar state 
of the constitution, consists of hemorrhages, which, however, are absent 
in some epidemics, though very common in others. For instance, Bre- 
tonneau makes no mention of it, whilst Bourgeois and Lespine found it 
a common occurrence, either from the nose, from the mucous membrane, 
or from the skin, and to such an extent as to occasion death. 

iv. M. Bretonneau relates a case of the present disorder complicated 
by gangrene of the pharynx. 

v. M. Guersent has remarked that from the third to the seventh 
day the patient may be attacked by broncho-pneumonia or catarrhal 
pneumonia, which at its commencement is very insidious, and apt to be 
masked by the symptoms of the angina. 

These are the chief complications. Other diseases, as enteritis, ery- 
sipelas, or the eruptive fevers, may occur, but they can only be regarded 
as coincidences. 

681. Causes. — That the same causes which give rise to simple pha- 
ryngitis may be influential in causing the present disease one can hardly 
doubt ; but it seems in general that something additional is requisite 
for its production. The crowding together of children in a close habi- 
tation may give rise to it, as was observed at St. Denis, by M. Bourgeois, 

1 Des Inflam. speciales du Tissu Muqueus et en particulier de la Diphtherite, &c, pp. 
240, et scq. 



PSEUDO-MEMBRANOUS PHARYNGITIS. 473 

Most frequently, however, the disease prevails as an epidemic, and 
those cases which would otherwise be simple pharyngitis take on this 
character, and exhibit the curdy disposition. 

Besides the epidemics which I have mentioned at the beginning of 
this chapter, M. Bretonneau mentions their prevalence at Tours in 
1818 and subsequent years; M. Girouard, at Sancheville, in 1824; M. 
Ferrand, in 1825, at La Chapelle-Veronge ; M. Guimier, at Vouvray, 
in 1826 ; M. Bourgeois, at the establishment of the Legion of Honor at 
St. Denis, in 1827-8 ; M. Trousseau, at Sologne, in 1828 ; by M. Baud, 
in the Canton de Vaud ; by M. L'Espine, in the Royal Military School 
of LaFleche, in the same year; and in the State of Ohio, by Dr. Welsh, 
in 1847-8-9. 1 

Some difference of opinion prevails as to whether the disease is con- 
tagious. From the facts collected by M. Guersent, from his own expe- 
rience and that of others, he has come to the conclusion that it is, and 
in this opinion Rilliet and Barthez concur. 

In its secondary form, the disease may occur in the course of scar- 
latina, typhus fever, measles, remittent fever, &c, adding much to the 
distress of the patient, and sometimes to the clanger of the primary 
affection. 

682. Diagnosis. — I. The presence of the false membrane will distin- 
guish diphtherite from simple or erythematous pharyngitis, although, 
on the first day of the attack, the aspect of the parts may be precisely 
the same. 

II. The peculiar characters of gangrene of the pharynx are equally 
Well marked, and so different from diphtherite that there is little danger 
of our confounding them ; the gangrenous eschar and odor, the loss of 
substance, and the absence of false membrane on the neighboring parts, 
are very characteristic, not to mention the difference in the symptoms 
and history of the two cases. Moreover, gangrene generally attacks 
children previously debilitated by disease, whereas primary diphtherite 
may occur in children who, up to that time, have been perfectly healthy. 
No doubt the two diseases may attack the same child, but it is certainly 
a coincidence only. 

683. Prognosis. — The prognosis of the disease will depend very much 
upon the extent of the disease, its complications, the state of the child's 
constitution, and the character of the epidemic. 

If the attack be limited to the pharynx, and occur sporadically, it 
is generally easily cured, according to MM. Bretonneau, Guimier, and 
others; although in one such case related by Bretonneau, and another 
by Rilliet and Barthez, death took place. 

When the false membranes extend into the larynx and trachea, we 
shall have croup with all its danger ; and when the skin takes on an 
inflammatory action, with or without false membrane, as in the epidemic 
described by M. Trousseau, death may occur from exhaustion. A like 
result may follow in those cases in which the disease appears at the oppo- 
site extremity of the mucous membrane, the vulva, or anus. 

In secondary diphtherite, the danger will probably depend more upon 

1 American Jourii. of Med. Science, July, 1850, p. 276. 



474 PSEUDO-MEMBRANOUS PHARYNGITIS. 

the primary disease, although, doubtless, the secondary affection will in- 
crease it. 

684. Treatment. — The indications of cure are not quite so simple as 
in the previous affections. Much will depend upon the extent of the 
disease, its disposition to penetrate into the larynx and trachea, the 
constitution of the child, and upon the character of the epidemic when 
the disease prevails extensively. Most writers, also, dwell upon the 
greater importance of topical applications. 

The principal caustic applications which have been employed are 
muriatic acid, nitrate of silver, powdered alum, and the chloride of lime ; 
and they are said to act both by preventing an extension of the false 
membrane, and also by changing the character of the inflammation. 
M. Bretonneau used the first of these applications ; and he recommends 
two thorough cauterizations, at an interval of twenty-four hours, after- 
wards milder applications. M. Guersent substituted the nitrate of silver 
for the muriatic acid ; but in using this we must take care that the stick 
is not broken and swallowed. The chloride of lime, calomel, or alum, 
can easily be applied to the diseased surface, either by the finger or by a 
small roll of lint. 

Some one of these remedies should be applied as soon as the distinct- 
ive characters of the disease appear, or as soon as the patient is placed 
under our care, and repeated as often as we may find necessary, judg- 
ing from the change produced by it. 

685. If the case be a slight one, occurring sporadically, and the child 
in good health otherwise, an emetic may be at once administered, the 
bowels properly freed, and the throat painted with a solution of nitrate 
of silver every day or every second day ; which will probably be sufficient 
to cure the disease. 

But if the case be more severe, the inflammation and swelling greater, 
and the child of a robust constitution, it will be well to commence with 
the application of a few leeches to the throat, followed by poultices. 
Broussais, Emmangard, and others, have ordered the application of 
leeches to the epigastrium ; but unless there were decided tenderness in 
that region, I do not think it would be necessary ; and in no case 
should blood be abstracted when there are symptoms of depression or 
exhaustion. After the application of leeches, the case must be treated 
by caustics, purgatives, and perhaps by an emetic. In the intervals of 
cauterization, the vapor of hot water may be inhaled three or four 
times a day, or a slightly acidulated gargle used equally often. 

Internally, small doses of calomel will be found useful, either alone 
or in combination with ipecacuanha. 

Emollient drinks, iced water, lemonade, or acidulated water, should 
be allowed, and an occasional warm bath or pediluvium will greatly add 
to the comfort of the patient. 

There is much difference of opinion as to the propriety of blistering 
the throat, and I confess that I agree with those who object to it as a 
rule. I do not deny that there are some cases which appear benefited 
by it, but in general I should much prefer simple poultices, or, if we 
wish to excite irritation, poultices of mustard and linseed meal, or a lini- 
ment sufficiently strong to redden the skin. 



PUTRID SORE THROAT. 475 

686. If the disease be epidemic, but not exhibiting a typhoid character, 
the treatment will be nearly the same ; a little more caution in apply- 
ing leeches, the prompt use of caustics, and their repetition each day 
until the surface exhibits an altered appearance, the exhibition of calo- 
mel, mild purgatives, emollient or acidulated drinks, &c. will be equally 
necessary. 

But if the epidemic show a typhoid character, we must make a consider- 
able change from the above plan. The parts must be cauterized, and 
the bowels kept free, but we must carefully abstain from bleeding, and 
from everything calculated to lower the system. For this form of the 
disease, a very useful gargle may be made with decoction of bark and 
nitric acid, from twenty to fifty drops of the latter to half a pint of the 
former. And in addition to this, we must administer bark, or ammonia, 
or both, internally, with a liberal use of wine, according to the circum- 
stances of the child. 

Wendt advises enemata of decoction of bark, and Rilliet and Barthez 
concur with him. 

The diet must be regulated according to the character of the attack : 
if there be much fever and acute inflammation, it should be mild and 
spare ; but when typhoid symptoms are present, the strength must be 
supported by beef-tea, broths, &c. 



CHAPTER XL 

PUTRID SORE THROAT. — GANGRENOUS ULCERATION OF THE PHARYNX. 

687. There exists considerable confusion among writers as to this 
disease ; some having described under this name an aggravated form of 
diphtheritic sore throat, attended by dark-colored crusts, bad smell, &c; 
and others on the opposite side having nearly denied the existence of 
such a disease. M. Bretonneau, I think, has proved that the angina 
maligna of many writers was a modification of diphtherite, but the ob- 
servations of M. Becquerel, MM. Rilliet and Barthez, and others, leave 
no doubt of the occasional occurrence of gangrenous ulceration; and, 
notwithstanding the opinion of the last-named writers, to which great 
respect is due, I cannot but believe that the "putrid sore throat" de- 
scribed by Dr. Fothergill, of London, was really this disease. 1 He 
states that the disease was first noticed in London, and that it re- 
appeared in 1742. Again, in the winter of 1746, " so many children 
died at Bromley, near Bow, in Middlesex, of a disease that seemed to 
yield to no remedies or applications, that several of the inhabitants were 
greatly alarmed by it, some losing the greater part of their children 
after a few days' indisposition. Some others of the neighboring places 
were affected at the same time with the like disease, which, from all the 

1 First published in 1748, and now included among Lis collected -works, p. 167. 



47b PUTRID SORE THROAT. 

accounts I have met with from those who attended the sick, was that 
here treated of. I am informed likewise that it raged at Greenwich at 
the same time." 

Gangrenous ulceration may attack the throat as a primary disease in 
children hitherto healthy, as in a case lately under my care ; but it 
much more commonly supervenes in the course of other diseases ; or 
ulceration of the mouth, previously existing, whether simple or aphthous, 
may assume a gangrenous character and appearance. 

688. Symptoms. — The disease may commence like a common sore 
throat, with some degree of fever, rigors, heat of skin, quick pulse, 
weariness, &c, but without exciting any alarm ; and the patient may 
then complain of soreness of the throat, pain and difficulty of swallow- 
ing, &c. On examination we find at first the pharynx and tonsils 
swollen, and of a dusky red, with perhaps a spot of commencing ulcer- 
ation, which enlarges daily, and shortly presents its peculiar characters. 

Or, as in Dr. Fothergill's cases, it may come on "with such a giddi- 
ness of the head as commonly precedes fainting, and a chilliness or 
shivering like that of an ague fit; and these interchangeably succeed 
each other during some hours, till at length the heat becomes constant 
and intense. The patient then complains of an acute pain in the head, 
of heat and soreness rather than pain in the throat, stiffness of the 
neck, commonly of great sickness, with vomiting or purging, or both. 
The face soon after looks red and swelled, the eyes inflamed and watery, 
as in the measles, with restlessness, anxiety, and faintness. The dis- 
ease frequently seizes the patient in the forepart of the day. As night 
approaches, the heat and restlessness increase, and continue till towards 
morning, when, after a short, disturbed slumber (the only repose they 
often have during several nights), a sweat breaks out, which mitigates 
the heat and restlessness, and gives the disease sometimes the appear- 
ance of an intermittent. If the mouth and throat be examined soon 
after the first attack, the uvula and tonsils appear swelled, and these 
parts, together with the velum pendulum palati, the cheeks on each side, 
near the entrance into the fauces, and as much of them and the pharynx 
behind as can be seen appear of a florid red color. This color is com- 
monly most observable on the posterior edge of the palate, in the angles 
above the tonsils, and upon the tonsils themselves. Instead of this red- 
ness, a broad spot or patch, of an irregular figure and of a pale white 
color, is sometimes to be seen, surrounded with a florid red, which white- 
ness commonly appears like that of the gums immediately after having 
been pressed with the finger, or as if matter ready to be discharged were 
contained underneath." "The appearance in the fauces continues to 
be the same, except that the white places become more ash-colored; and 
it is now discernible that what at first might have been taken for the 
superficial covering of a suppurated tumor, is really a slough concealing 
an ulcer of the same dimensions." 1 

Dr. Fothergill mentions other symptoms worthy of notice. The first 
is an erythematous eruption on the face, neck, hands, and breast, with 
some tumefaction, and occurring generally on the second day. Another 
phenomenon is a swollen, hard, and painful condition of the parotid 

1 Works, pp. 202-205. 



PUTRID SORE THROAT. 477 

glands on each side ; and if the disease be violent, the neck and throat 
are surrounded with a large cedematous tumor, sometimes extending 
itself to the breast, and, by straightening the fauces, increasing the 
danger. 

Delirium was a frequent symptom in those cases ; occurring the first 
night, bearing a direct relation to the feverish exacerbations, and 
equally relieved by the perspiration which broke out towards morning. 

The pulse was very quick for some days, but although the uvula 
and tonsils were much inflamed, the difficulty of swallowing was less 
than might have been expected. The offensive putrid smell was not 
only evident to those around, but even to the patient himself. In severe 
cases the disease extended to the inside of the nostrils, which was of a 
deep red or livid color, and a putrid sanies was discharged, so corrosive 
as to excoriate the parts over which it flowed. The lips also, and the 
margin of the anus, occasionally exhibited the same appearance. Dr. 
Fothergill thinks it probable that the diarrhoea may be owing to this 
discharge being swallowed. 

Hemorrhages from the nose, mouth, and ears sometimes occurred ; in 
general to a moderate amount, but in some cases proving suddenly fatal. 
They seemed to result from the injury of some arterial branch by the 
ulceration. 

The duration of this disease was variable. Some seemed to mend 
after the second day; others continued three, four, or six days, even 
when favorable, and the decline of the disease was marked by the dis- 
appearance of the eruption, the subsidence of the pulse and fever, and 
the throwing off of the sloughs, and the more healthy appearance of the 
ulcers. 

In unfavorable cases the diarrhoea persists ; " they generally spit 
very little ; the fauces appear dry, glossy, and livid; the external tumor 
grows large ; they void their excrements without perceiving it, and fall 
into profuse sweats ; respiration becomes difficult and laborious ; the 
pulse sinks ; the extreme parts grow cold ; and death in a few hours 
closes the scene." 1 

689. If, as appears to me, this disease were really gangrene, it wa3 
the primary form, and differed very widely in the acute character of its 
symptoms from the secondary form described by Eecquerel, Guersant, 
Rilliet and Barthez, &c. In the latter the chief general symptoms 
resulted from the primary malady, whatever that might be, but the 
occurrence of the gangrene was chiefly marked by a profound alteration 
of the countenance, great depression, and the small, quick pulse. Loss 
of appetite, thirst, and diarrhoea also existed, but they may have been 
the result of the original disease as well as of the gangrene. 

The local symptoms were often obscure and sometimes uncertain. 
The fetid odor of the mouth was invariable, and of great value in those 
cases where the ulcer could not be seen, either from its situation or the 
difficulty of opening the mouth. 

In none of Rilliet and Barthez's cases did the patient suffer any pain, 
and deglutition was easily effected, and not marked by the regurgitation 
of liquids through the nose. In one case, where the gangrene was con- 

1 Works, p. 229. 



478 PUTRID SORE THROAT. 

siderable, the patient drank and ate solid food until the day of her 
death. 

M. Guibourt mentions that one of his patients suffered severe pain 
and difficulty of swallowing; and in a case of M. Constant's, the patient 
incessantly put his finger into his mouth, as if to remove something that 
annoyed him. The swelling of the submaxillary glands, and of the cel- 
lular tissue, was not remarked except in one case, nor the abundant, 
fetid, sanious salivation. 

As we might expect, the course of so serious a disease supervening 
upon another complaint, and in constitutions so enfeebled, is very rapid ; 
sometimes, too, three or four days terminate life, and the case rarely 
passes the sixth. 

690. Complications. — Of course, in secondary gangrene, some of the 
concomitant diseases which have been noticed were merely coincidences; 
nevertheless certain of the complications appear to be either an exten- 
sion of the disease, or closely connected with it. 

I. The gangrene may extend gradually to the neighboring parts, the 
nares, the mouth, the oesophagus, or the larynx. 

II. Even distant organs may exhibit a similar morbid action ; thus 
the uvula externally, or the lungs internally, have been attacked by 
gangrene during the course of gangrene of the pharynx. 

III. M. Guibourt mentions a case in which oedema of the glottis occur- 
red. 

iv. Pneumonia may occur, but it is less frequent than in gangrene of 
the mouth. 

V. In nine out of twelve cases there were tubercles in the lungs, but 
this we must regard merely as a coincidence. 

vi. I have already alluded to the occurrence of fatal hemorrhage in 
Dr. Fothergill's cases. I have seen the child seriously weakened by it, 
though not destroyed ; but Dr. Mills has related two cases in which 
death occurred suddenly from this cause. 1 

691. Morbid Anatomy . — At the commencement of primary gangrene 
we find the mucous membrane of a florid or deep red color, with a white 
or ash-colored spot, according to Dr. Fothergill, or with an unhealthy 
looking ulcer at a somewhat later period. This ulcer may occupy one 
or both tonsils, the back of the pharynx, the posterior nares, or the 
commencement of the oesophagus; and as the disease advances we shall 
probably find it extending on either side : I have seen the uvula, velum, 
and soft palate entirely destroyed by it. The surface, at first grayish 
or ash-colored, gradually becomes dark brown. Dr. Fothergill ob- 
serves : " When the disease is of the mildest kind, a superficial ulcera- 
tion only is observable, which may casually escape the notice of a person 
unacquainted with it. A thin, pale, white slough seems to accompany 
the next degree ; a thick, opaque, or ash-colored one is a further ad- 
vance ; and if the parts have a livid or black aspect the case is still 
worse. These sloughs are not formed of any foreign matter spread 
upon the parts affected as a crust or coat, but are real mortifications of 
the substance, since, whenever they come off or are separated from the 

1 Edin. Med. and Surg. Journal, Jan. 1814. 



PUTRID SORE THROAT. 479 

parts they cover, they leave an ulcer of greater or less depth, as the 
sloughs were superficial or penetrating." 1 

A dark reddish-brown hue may be given to the slough by the oozing 
of blood, but the brown color may exist independently. 

The odor is fetid, overpowering, perceived even by the patient, and 
rendering the room intolerable. . 

Portions of the slough may be cast off, but it is rapidly reformed ; 
the surface underneath has generally an unhealthy appearance. 

692. The secondary gangrene described by the French writers I have 
named may be either circumscribed or diffused. 

I. Circumscribed Gangrene generally occupies the lower portion of 
this canal, near its junction with the oesophagus, either on its posterior 
or anterior surface, and consequently it is not within view during life, 
and we are mainly left to infer it from the putrid smell, and the acces- 
sion of the symptoms I 'have mentioned. The gangrenous spots are 
sometimes oval, sometimes round, varying in size from a pea to a shil- 
ling, and it is very probable that the larger are formed by the coalesc- 
ing of several smaller ones. The surface of these patches is depressed, 
gray, blackish, or quite black, the edges clear cut and yellow, and with 
the characteristic gangrenous smell. 

Beneath the slough the mucous membrane and subjacent tissue are 
destroyed, and so deeply, in some cases, that the muscles are clearly ex- 
posed. The surrounding mucous membrane appears unchanged, neither 
red, nor thickened, nor softened. When the slough is thrown off we 
find an ulcer with more or less loss of substance, and which is occasionally 
covered afterwards by a layer of false membrane. 

However limited and superficial the gangrene may be at first, it may 
ultimately penetrate into the larynx or extend to the epiglottis ; or it 
may be confined to one or other tonsil. 

ii. Diffused Gangrene. — This form differs widely from the former ; 
the eschars are quite irregular, and may occupy the entire vault of 
the palate, the velum, tonsils, and pharynx. The limit between the 
diseased and healthy tissues is not clearly defined, although the edges 
are sometimes formed by the detached epithelium. Sometimes the 
gangrene is superficial, and though extensive, scarcely penetrates below 
the raucous membrane. The surface is unequal, of a grayish black, 
easily removed by the scalpel, and of unequal thickness. The sub- 
mucous tissue is of a violet color ; but when the deeper tissues are 
affected they become of a black color, and present the appearance of a 
mass of detritus. 

This form is generally of considerable extent, and spreads to all the 
neighboring parts, so that the palate, the cheeks, the gums, or on the 
other hand, the epiglottis, and larynx, may be attacked. 

Diffused gangrene is rather more common than the circumscribed 
form. Of thirteen cases, eight had diffused gangrene, and in seven 
it occupied the velum palati, the tonsils, and a great part of the 
pharynx. 2 

1 Works, p. 237. 

2 Rilliet and Bartliez, Mai. des Enfaus, vol. ii. p. 169, et seq. 



480 PUTRID SORE THROAT. 

693. Causes. — Dr. Fothergill found the disease most frequent from 
September to December, but the peculiar condition of the weather 
seems to have little or no influence. It more frequently attacks chil- 
dren than adults, and children under six years rather than over, accord- 
ing to Rilliet and Barthez. Dr. Fothergill states that more girls than 
boys suifer from it ; but out of Rilliet and Barthez's thirteen cases, 
seven were boys and six girls. 

All are agreed that children of feeble constitutions, or whose health 
has been destroyed by previous disease, are very much more exposed 
to it ; and there are certain diseases whose course it complicates as a 
secondary affection. These are the eruptive fevers, measles, scarlatina, 
or smallpox, and likewise pneumonia, peritonitis, diphtheritis, and 
typhus fever. 

I have already mentioned that the milder forms of ulceration of the 
mouth and throat do occasionally assume a gangrenous character, pro- 
bably owing to the peculiar state of constitution induced by previous 
disease. 

It is said to prevail epidemically, but we have no very well authenti- 
cated information upon the subject. M. Becquerel, indeed, has observed 
a kind of epidemic in the Hopital des Enfans, and has recorded his ob- 
servations. 1 Some writers seem to consider it contagious. Dr. Fother- 
gill remarks that when one child of a family has it all the rest take it 
if they are not kept apart ; but I should be very much inclined to doubt 
its being directly communicated from one person to another. 

694. Diagnosis. — In cases where the gangrene is primary, there is 
not much difficulty in recognizing it ; the ash-colored, brown, or black 
slough, the gangrenous smell, and loss of substance, would alone be 
sufficiently characteristic ; but in Dr. Fothergill's cases, there was 
oedema of the neck, and rapid sinking in the mor< 
were different from other affections of the throat. 

In secondary gangrene, when circumscribed, and situated low down 
in the pharynx, the diagnosis may be very difficult; and I need not say 
that the age of the patient, and the difficulty of minutely investigating 
the throat, will increase the chances of our overlooking or confounding 
the disease. In such cases the fetid odor will be very important ; but 
as that may arise from gangrene of the mouth or lungs, we can only 
fix upon the larynx as its seat by finding those other parts free from 
disease. It is true, as Rilliet and Barthez observes, that it will not 
signify if we do mistake as to this point ; but it is very important that 
we should not mistake diphtherite for gangrene, to which, in some cases, 
it bears a strong resemblance, the odor being occasionally fetid, and 
the sloughs dark-colored. If we have watched the case from its com- 
mencement, we shall not be likely to make this mistake ; but if not, or 
if we should still be doubtful, the application of caustic, by changing 
the vitality of the parts, and effecting the separation of the apparent 
sloughs, will show, in cases of diphtherite, that the mucous membrane 
has not really been destroyed. 

695. Prognosis. — The disease is very serious, nay, very fatal. A 

1 Gazette Medieale, 1843. 



ABSCESS BETWEEN THE PHARYNX AND THE SPINE. 481 

great proportion of cases of primary gangrene die, and a still larger 
number of secondary cases. The profound destruction of parts, the 
disposition to spread, the unhealthy condition of the patient, added 
to the injury inflicted by the primary disease, render recovery very 
hopeless. 

696. Treatment. — The result of Dr. Fothergill's experience was that, 
however acute the symptoms might be, the patient was never relieved 
by bleeding. He gave a mild emetic, occasionally following by warm, 
aromatic, and stimulating medicines, wine, broths, &c. Locally, he re- 
commends gently stimulating gargles ; in mild cases, a stronger one, 
with the mel Egyptiacum in more severe ones. Means are also to be 
taken to arrest the diarrhoea and hemorrhage, if present. 

Rilliet and Barthez recommend an attempt to limit the extent of the 
gangrene by muriatic acid or the application of the chloride of lime to 
the parts affected. An occasional emetic may favor the separation of 
the eschar, and may prevent the injurious effects of the putrid detritus 
which may have been swallowed. Gargles of decoction of bark, with 
nitric acid, are useful ; but if the child be too young to gargle, they 
may be injected with a syringe. 

Internally, the constitution must be invigorated by a liberal allow- 
ance of bark (syrup of quinine is a pleasant form for children), ammo- 
nia, wine, broths, &c. 



CHAPTER XII. 

ABSCESS BETWEEN THE PHARYNX AND THE SPINE. 

697. Before passing to the consideration of the diseases of the 
stomach, I feel it right to notice the disease so well described by my 
friend, Dr. Fleming, in his interesting paper, 1 both on account of the 
alarming symptoms to which it gives rise, its simple method of cure, 
and because I am not aware that it has been noticed by any author 
before Dr. Fleming, as occurring during infantile life. 

The disease in question is an abscess formed behind the pharynx, 
and between it and the spine ; and, when acute, it appears to consist 
in inflammation and suppuration of the loose cellular tissue in this 
situation, and occasionally of a lymphatic gland, not unfrequently to 
be found here ; when chronic, it partakes of the nature of scrofulous 
abscesses. 

It may occur at all periods of life, from infancy to manhood. Dr. 
O'Ferrall has recorded a case of this affection at the age of four months, 
which Dr. Fleming witnessed in consultation with him. 2 

698. Symptoms. — The symptoms are very characteristic, although 

1 Dublin Medical Journal, vol. xvii. p. 41. 

2 Dublin Hospital Gazette, 1845, March 1, p. 20. 

31 



482 ABSCESS BETWEEN THE PHARYNX AND THE SPINE. 

at first one might attribute it to some affection of the nervous system. 
They may be divided into the premonitory and the essential. " The 
'premonitory indication of local uneasiness, but yet common to all affec- 
tions of the throat, complained of or otherwise, according to the age of 
the child, and, on examination, not accompanied with proportionate 
visible lesion. The essential, often very suddenly supervening, and 
indicated by derangement of the cerebral, circulating, and respiratory 
symptoms, alternating with the comparatively healthy condition of 
those systems, according to the alteration in the position of the indivi- 
dual; fixed and retracted state of the head, with rigidity of the mus- 
cles at the back of the neck, and more or less locked state of the jaws ; 
painful deglutition, impossibility of swallowing, solids and fluids con- 
vulsively darted forward through the mouth and nose ; repeated acts of 
deglutition, without the presence of any fluid in the mouth, and, on 
examination of the fauces, a firm projecting tumor felt beyond the base 
of the tongue, and, if seen, presenting a smooth, rounded, highly vas- 
cular appearance behind the soft palate, usually occupying the median 
line, but occasionally inclining to either side. These essential symp- 
toms, accompanied with the ordinary characteristics of suppurative 
fever." "Fever, more or less sthenic in its character, according to the 
peculiarity of constitution of the child, is always present, and, I think, 
precedes the development of the local symptoms." 

699. As regards the chronic abscesses, the " symptoms attendant 
upon them are in a much milder degree of the same character with the 
acute ; and perhaps the more prominent are the remarkable effects pro- 
duced on the respiration by change to the recumbent posture. There 
is absence of fever, and throughout the day the child is free from any 
obvious illness, able to play, and join in the amusements of other child- 
ren. I have known them not to complain of any uneasiness in the 
throat, and attention to be directed to it from the raucous breathing 
during sleep. In fact, the symptoms much resemble those of common 
scrofulous induration of the tonsil. They are, hence, cases of compara- 
tively minor importance ; there is time to investigate them. Indeed, 
with them may be complicated chronic enlargement of the tonsils. I 
have met with them after scarlatina, after variola, and after measles. 
In fact, they are some of the sequelas of those cutaneous diseases, and, 
like them, may be accompanied with suppuration of the internal or ex- 
ternal ear, and so come under the description of similar cases already 
alluded to as described by Petit." 

700. Diagnosis. — When the tumor is large, and the cerebral symp- 
toms intense, the case may not unlikely be set down as one of disease 
of the brain; or, at an earlier period, it may be mistaken for disease of 
the cervical portion of the spine. In all such cases, a careful examina- 
tion of the throat should be made, as the presence of the tumor will 
remove such doubts at once. Moreover, the difficult deglutition, the 
regurgitation of fluids through the nose, &c, point decidedly to some 
mechanical obstruction, and an examination will at once prove that it is 
not from enlarged tonsils, but from a firm projecting tumor beyond the 
base of the tongue, and generally in the centre of the pharynx. 

701. Treatment. — Dr. Fleming's experience has proved that surgical 



DISEASES OF THE STOMACH. 483 

interference is as effectual as it appears to be essential from the symp- 
toms ; and " not alone from the fact of certain fatal results from me- 
chanical pressure on, and interference with, vital organs, but also from 
the situation of the abscess being particularly favorable to extensive 
diffusion." In one case only has Dr. Fleming seen a spontaneous open- 
ing occur ; the abscess was situated high up, and the matter passed 
through the nose. 

For increasing the facility of the operation, Dr. Fleming has con- 
trived an instrument consisting of a trocar about four inches long, one 
extremity of the canula being slightly curved, the other with a ring on 
its upper surface to receive the forefinger ; into this canula was passed 
a jointed stiletto, with, at its opposite extremity, a ring for the thumb, 
and a movable screw, to graduate the projection of its point." 

The greatest caution must be observed. An assistant must hold the 
head firmly, and be ready to throw it forward when the puncture is 
made. The operator should pass his left forefinger to the back of the 
pharynx, and, fixing the point of it upon the tumor, use it as a guide 
to the trocar, so as to place it on the most prominent part of the tumor, 
when pressure on the stiletto will effect the object in a moment. 

Dr. O'Ferrall recommends that the operator should stand behind the 
patient, and pass the " forefinger of his left hand between the palate 
and the tongue, carefully avoiding the latter, until it reach the abscess. 
The trocar is thus readily guided to the point intended to be punctured, 
and thus all danger to the surrounding parts is avoided." " Dr. O'Fer- 
rall, in similar cases, would in future prefer a straight bistoury, having 
the cutting part short, as the density of the covering of such abscesses 
renders the plunge of a trocar unsafe." 

For fuller details, illustrated by very interesting cases, I must refer 
my readers to Dr. Fleming's excellent paper. 



CHAPTER XIII. 

DISEASES OF THE STOMACH. 

702. Before proceeding to describe the different affections of the 
stomach and intestinal canal, I shall avail myself of the researches of 
Billard and Rilliet and Barthez, to lay before my readers the condition 
of the mucous membrane of this canal in health, as it is quite possible 
for an uninstructed person to mistake some of these appearances for 
the result of disease. 

Billard remarks : " Now, from the examination of the stomach in 
several embryos and foetuses, it appears that the internal surface of this 
organ is of a light red color, more or less marked ; that the internal 
membrane soon shows the existence of villi ; that they are more evident 
than in adults ; and that this internal membrane, towards the fourth or 
fifth month, less adherent than the other membranes, may be separated 



484 DISEASES OF THE STOMACH. 

from them with great ease. Meckel observes that it is very thick 
towards the fourth or fifth month of pregnancy. At first sight it 
might be thought to be the case, but it should be remembered that the 
muscular coat is almost always raised with it ; and the subjacent cellular 
membrane, which, not being quite so distinct, is added to the mucous 
membrane, adheres to it, and is raised at the same time. At birth, the 
stomach of an infant is but little dilated. It incloses a quantity of 
ropy mucus, with which there is sometimes mixed some small grumous 
particles, apparently composed of concrete mucus. In stillborn children 
there is found a layer of mucus, more or less thick, adhering to the 
surface of this organ. Upon raising it with the nail or the back of the 
scalpel, the internal membrane is seen beneath this layer perfectly 
healthy. This mucus disappears after a few days ; and this is, doubt- 
less, what several authors, and Capuron in particular, mean by the 
name saburra, the removal of which it was necessary to effect imme- 
diately after birth. We shall see that the same thing exists in the 
intestinal tube, when we shall be able to appreciate more fully the 
nature of the advice given for the expulsion of this substance." 1 

703. The same author, after describing the gradual formation of the 
intestinal tube, and its condition at different periods of foetal life, pro- 
ceeds to examine the state of this organ at birth, the matters which it 
contains, and the phenomena of the first alvine evacuations. " The 
duodenum has a rosy appearance, which is continued to the jejunum, 
but is less remarkable in the ilium. The jejunum has some traces of 
the valvulae conniventes ; the villi are equally developed, and very 
often in the jejunum are found some separate mucous follicles, about 
the size of the head of a pin, and almost always white ; some follicular 
plexuses, slightly projecting, also white, and often with a little black 
point on the top, as observed in adults, are met with in the ilium. The 
ilio-csecal valve is a little projecting, and the opening which it sur- 
rounds extremely small ; in most children it would be difficult to pass 
even a crow-quill. At this age it prevents the regurgitation of sub- 
stances and even gas from the great intestines to the small, but allows 
a free passage for the contents of the small intestines to the large. 
This can easily be proved by passing a current of water through one or 
the other of the extremities of the digestive tube ; in the one direction 
the water passes freely, while in the other it will meet with an insur- 
mountable obstacle. Neither do the ccseum or colon as yet present 
their depressions and prominences in as distinct a manner as afterwards, 
or as they appear in adults. After birth, the internal membrane of the 
digestive passages gradually loses its habitual color, and becomes of a 
milky white, and continues for some time flocculent. During the whole 
of the first year it is remarkable for this appearance, and for the abun- 
dant secretion of mucosity. The matters contained in the intestinal 
canal of a young infant vary with reference to the color and consistence. 
Generally there is found in the duodenum and jejunum thick mucous 
substances, of a white color, adhering to the walls of the intestines, 
sometimes collected together in certain parts, and sometimes spread 

1 Mai. des Enfans, Stewart's Trans., p. 238. 



DISEASES OF THE STOMACH. 485 

over them. They are often colored yellow, owing, probably, to the 
bile ; and there are also found balls or small masses of a green color, 
which are observed in the intestines a long time after the expulsion of 
the meconium. I have found them in a child eight or ten days old ; it 
would appear that they do not possess any irritating property, for their 
contact never produces inflammation of the mucous membrane. It is 
very common, also, to find about the ilio-csecal region an accumulation 
of yellow and frothing liquid ; the large intestines are always filled 
with meconium, of the consistence of pitch, and of a deep green color, 
a circumstance noted by all authors." "When all the liquid parts of 
the intestinal tube are removed, there still remains a layer of thick 
mucus adhering to the internal surface of the canal, forming on it a 
kind of plastering. This layer may be raised with the nail, under the 
form of a pellicle, resembling, to a superficial observer, portions of the 
mucous membrane itself. It is probably this layer of mucus that cer- 
tain practitioners regard as vitiated matters, or saburra, for the expul- 
sion of which they have recommended purgatives from the time of 
birth. 

" But whether this mucus be for no other object than protection of 
the mucous membrane when exposed to the contact of unaccustomed 
aliments, or whether it be a simple deposit of a fluid contained for a 
long time in the alimentary canal, attaching itself, without any use, to 
its surface, it never remains there but for a short time, and detaches 
itself, without the assistance of any purgative, by a kind of natural 
exfoliation. This exfoliation occurs in very thin lamellae, which, being 
rolled together, form the small white flocculi so frequently met with in 
the stools of young children ; and where the surface of the duodenum 
or jejunum is colored with bile, it is this layer of mucus that is colored, 
so that in removing it the color also disappears from the intestine." 
" As soon as the child has commenced a new kind of alimentation, the 
contents of the intestines change their appearance, the phenomena of 
digestion becoming, with respect to the manner in which it is performed, 
analogous to what it will be during the remainder of life. A great deal 
of importance is usually attached to the first discharge from the bowels ; 
and nurses are eager to administer to a child just born some mild pur- 
gative, under the fear of retaining, for too long a time, a substance 
which absurd prejudices have induced them to regard as irritating, and 
as capable of exercising a serious effect on the system. I am far from 
entertaining any such ideas, for I can see in the meconium no irritating 
or chemical property ; but I conceive that a prolonged retention of this 
matter may produce, if it be not evacuated, effects analogous to those 
which obstinate costiveness produces." 1 

704. MM. Rilliet and Barthez have drawn their observations from 
children somewhat older. According to their statement, the gastro- 
intestinal mucous membrane is of a grayish-white, or clear rose gray, 
the color varied by venous ramifications. Its thickness, which is not 
considerable, varies in different regions, as does its tenacity. The sub- 
mucous tissue is of a dull white color, rather thin in general, resisting, 

1 Mai. des Enfaas, Stewart's Trans., p. 273. 



486 DISEASES OF THE STOMACH. 

and intersected by venous arborizations, more voluminous but less nume- 
rous than those of the mucous membrane. The muscular coat under- 
neath is recognizable by the direction of its pale or rose-colored fibres. 

The mucous membrane varies in different situations ; it is thinner and 
paler in the great cul-de-sac of the stomach, less consistent, and less 
firmly adherent to the subjacent tissue ; and this change of character is 
often so sudden and so complete as to give the appearance of a line 
marking the limits of the cul-de-sac ; in other cases the transition is 
gradual. The capacity of the stomach varies ; it is often considerable, 
but, unless disease be present, this is a matter of no moment ; in other 
cases the organ is much contracted. Of course the smoothness of the 
internal surface will be modified by these conditions. 

The mucous membrane of the small intestines, often colored by its 
contents in its superior portion, is of a grayer color than that of the 
stomach ; it is tolerably thick in the duodenum, but gradually diminishes 
towards the inferior termination. Its adherence to the subjacent tissue 
is but slight, and slips may easily be raised even close to the valvulae 
conniventes. The isolated follicles are contained in the thickness of the 
mucous membrane, and are not visible except under the influence of 
disease. The patches of follicles are, on the contrary, always, visible 
along the free border of the intestine, and increasing in number towards 
its inferior portion, as in the adult. Numerous small black points are 
also observed, sometimes scattered irregularly, in other cases collected 
in different parts, and giving a grayish-black or black color to that part 
of the surface. 

In the large intestine the mucous membrane is thin at first, and goes 
on increasing to the rectum, and the authors remark that it is always 
thinner at the lower side of the natural obstructions of the canal, e. g. at 
the cardia, pylorus, caput caecum coli ; and from each of these points it 
gradually increases in thickness until we arrive at the next obstacle. 
The mucous membrane of the caecum permits a number of venous rami- 
fications, which disappear lower down, or only reappear in the rectum; 
and we find a considerable number of follicles, each marked by a gray 
spot, with a small opening of a darker color, which leads to its cavity. 

705. Let me now point out a few of the changes which take place 
after death, and which require to be carefully distinguished from those 
which are the result of disease. 

I. Obeying the physical laws, the fluids after death gravitate to the 
inferior parts of the body, and in the intestines we therefore find the 
vessels of the most depending portions filled with blood, and forming 
more or less extensive arborizations, which, however, are not always 
present, nor are other parts exempt from the same appearance. 

II. These arborizations, however, are not always cadaveric ; that is, 
they may be produced immediately before death, or in the act of dying, 
when the termination is accompanied by general congestion, as in 
asphyxia. When this is the case, the vessels have a deep violet color, 
and are rather situated in the submucous than the mucous tissue. 

III. At a later period the blood escapes from the vessels and colors 
the mucous membrane, which it penetrates as if by imbibition, forming 
large spots of a dull red color, in which no vessel can be discovered. 



DISEASES OF THE STOMACH. 487 

In other cases the blood distils through the membrane, and colors the 
mucus of the intestinal canal ; or it may be effused beneath the mucous 
membrane, following the sinuous track of the vessels from which it 
escapes. 

IV. At a still later period, the mucous membrane acquires a green 
tinge, similar to what may have been previously observed on the abdo- 
minal parietes ; this is an evidence that putrefaction is considerably 
advanced. 

V. There is another change about which there is considerable dif- 
ference of opinion ; I allude to softening of the mucous membrane, 
which by some has been regarded as the product of disease, and by 
others as a cadaveric change, and I can scarcely doubt that both are 
right. As far as my knowledge extends, I am quite prepared to agree 
with Rilliet and Barthez, who observe : " In conclusion, we believe 
that simple ramollissement of the stomach, and especially of its greater 
cul-de-sac, may exist both as a disease and as a cadaveric phenomenon; 
but that, considering the circumstances of temperature and putrefaction 
in which we ordinarily find it, we regard it, when discovered by dissec- 
tion made twenty-four or forty-eight hours after death, as more fre- 
quently cadaveric than morbid. The intestinal mucous membrane, on 
the other hand, undergoes this change more frequently from disease 
than as a cadaveric change." 

706. In conclusion, I will just enumerate the principal pathological 
changes which may be observed in the mucous membrane. 

I. Redness in the form of arborizations, bands, or vascular lines, or 
uniform. 

II. Softening, in which the mucous membrane is reduced to a kind of 
pulp, so that in extreme cases it may be scraped off, but cannot be 
raised in strips at all. This degree generally coincides with the uni- 
form red color. 

III. Thickening. — This change may occur with or without softening; 
it gives prominence to the parts so affected, whether only a few points 
or a more extensive surface. The increased thickness is demonstrated 
by carefully cutting through the mucous membrane only, in different 
parts. These three changes are the result of simple inflammation, and 
may be observed in any part of the intestinal canal. 

IV. False membranes, which may be more common than is supposed, 
but which are removed as secreted by the passage of matters through 
the intestinal canal. They may be deposited in small white patches 
here and there, or they may form a more extensive thin layer, white, 
gray, or yellow, slightly adhering to the mucous membrane, and often 
mixed with the fsecal matter. 

V. Ulcerations. — These are sufficiently common in typhoid fever and 
tubercular disease, and may be seated either in the mucous membrane 
or in its follicles. 

VI. Pustules. — It is very rare to meet with pustules in the stomach 
or intestinal canal, although such are recorded by Rilliet and Barthez. 

VII. Softening, non-inflammatory. — Three forms have been noticed 
by the authors just quoted : — 1. Simple or pultaceous ; 2. Gelatini- 
form ; and 3. White or opaline ramollissement. 



488 INDIGESTION. 

Although the usual signs of inflammation may be absent in these 
cases, it is by no means certain that the morbid change is not a more 
distant result of inflammation. The evidence we possess, carefully 
examined, would, I think, lead us to the conclusion that the colorless 
softening, without vascularity, -is probably, the termination of a series 
of morbid actions, of which inflammation was the beginning. 



CHAPTER XIV. 



INDIGESTION. — VOMITING. — WEANING BRASH. 

707. The affection which has been described under the term vomiting, 
and more recently termed indigestion, differs very considerably from 
the adult disorder so designated, although it appears equally independ- 
ent of organic disease in many cases. 

Vomiting is, no doubt, the prominent symptom, but we must distin- 
guish between that which results from an unhealthy or irritable condi- 
tion of the stomach, and that which is merely the expulsion of an excess 
of food. It is a natural effort of the stomach of infants, and a great 
advantage, that, when too much food has been swallowed, the excess is 
returned, whilst the proper quantity is retained, and the child is saved 
from the consequences of over-feeding. This is a species of organic 
intelligence which supplies the place of that knowledge which is after- 
wards acquired. " The milk is generally thrown off in an unchanged 
condition, and the infant is so little annoyed by the vomiting, that it 
will often preserve its usual placid and cheerful countenance while the 
milk is regurgitating from its stomach. This variety of vomiting may, 
therefore, be regarded rather as a salutary than a morbid occurrence ; 
for the superabundant nourishment, with which the digestive organs 
are habitually overloaded, would, doubtless, soon give rise to indigestion, 
and its various disagreeable consequences, if the stomach did not regu- 
larly relieve itself by throwing off a portion of its oppressive load." 1 
Common sense will teach the mother in such cases to diminish the 
quantity of milk the child is allowed to take at each nursing, until it is 
reduced to the capacity of the digestive powers, and no other treatment 
will be necessary. 

708. But the vomiting which occurs in the disease I am describing, 
does not necessarily result from the stomach being overfilled, but from 
its incapacity to digest what it has received, and an irritability which 
occasions it to reject it. It may be originally caused by over-feeding, 
but the effect continues after the cause has ceased. 

This indigestion may occur at any age. I shall notice it as we see it 
during suckling, after weaning, and at a later period. 

709. Symptoms. — During the first year of life, while the infant is 

1 Eberle on Diseases of Children, p. 205. 



INDIGESTION. 489 

still at the breast, the earliest symptoms of the disorder we shall be able 
to observe will be a pallid look, languor, and considerable discomfort. 
The infant is evidently unwell ; it cries and whines, and appears never 
easy except when at the breast. It sucks greedily, without appearing 
satisfied, and shortly afterwards vomits the milk, either fluid as it re- 
ceived it, or curdled (and not a small portion — the surplus — but the 
whole, or nearly so), with evident distress, paleness of face, &c. 

A good deal of stress has been laid upon the fact of the milk being 
curdled or not, as an evidence of the presence of a morbid amount of 
acid in the stomach. Undoubtedly it is not a natural state when the 
milk is rejected as a solid, firm curd, but it is certainly a mistake to 
suppose that no change takes place in the fluidity of the milk in healthy 
digestion. Underwood remarks : " Not that the milk ought not to 
curdle in the stomach, which it always must, in order to a due separa- 
tion of its component parts, and which is the chief, if not the only 
digestion it undergoes in the stomach;" 1 and experience confirms his 
observation, that it is only when the curdling is in excess that it is to 
be regarded as an evidence of disease. 

Upon this excessive coagulation, M. Billard has the following ob- 
servations : "Van Swieten and Rosen have remarked that it is very 
common to meet with milk coagulated in the stomach without being 
digested. The authors first mentioned attribute it to the superabundance 
of acid in the stomach. A very evident acid smell is often detected in 
the mouth of a child; like that, for instance, which is observed after an 
attack of indigestion. I found in fifteen infants that died with other 
affections than those of the digestive organs, the stomach filled with 
coagulated milk ; there were but three exhibiting a slight injection of 
the stomach ; in the remaining twelve the walls of this organ were 
white and perfectly healthy. I am inclined to think that this coagula- 
tion of milk proceeded from some other cause than inflammation. Does 
this result from the milk taken by the child abounding in caseine, or is 
it the presence of acid in the stomach that so quickly coagulates this 
fluid ? Does this acid exist, in the first place, in the stomach ? Is it 
the result of the decomposition of the milk ? Does this indigestion 
depend upon the want of vital activity and nervous action which is dis- 
played in the stomach during the operation of the digestive functions ? 
These are questions I am unable to solve ; but, whatever be the cause 
of this phenomenon, I point it out as the effect of a true gastric indi- 
gestion, without inflammation of the organ, and without apparent lesion 
of its walls ; and I wish particularly to direct the attention of physicians 
to this fact, that they may not be led to conclude that a child is affected 
with gastritis whenever it is unable to digest the milk that it has taken, 
or when the milk is vomited some time after in a coagulated form." 2 

So that a minor degree of coagulation being a part of the healthy 
process of digestion, an excessive degree may be owing either to ex- 
cessive acid, deficient nervous power or vital inaction ; and, on the other 
hand, milk vomited unchanged, after it has remained some time in the 

1 On Diseases of Children, p. 223. 

2 Mai. des Enfans, Stewart's Trans,, p. 243. 



490 INDIGESTION. 

stomach, is an equal evidence of an incapacity of digestion. Dr. Dewees 
says: " If there be a deficiency of acid in the stomach, and a vomiting 
be produced, the milk will come up unchanged. Nausea almost always 
attends this variety ; the child may be observed to become pale, and 
evidently to struggle against the efforts of its revolting stomach. The 
milk is rejected with great force in a large column; and not unfre- 
quently a portion passes through the nostrils." 1 

710. To return. The child is attacked by frequent vomiting, after 
which it looks pale and exhausted ; but it is as eager as ever to suck 
again. Occasionally much alarm has been felt in consequence of blood 
being mixed with the ejected milk ; but this is owing to the nipple hav- 
ing cracked, and the child having drawn blood when sucking. 

The bowels are not necessarily affected ; they are sometimes in a 
natural state, sometimes constipated, and occasionally too free. Nor 
does the child suffer generally from pain or tympanitis, although the 
stomach may be troubled with flatulence. 

This alternation of sucking and vomiting is gradually followed by 
emaciation and exhaustion, and a sinking of the vital powers, but there 
is no evidence at all of inflammation of the stomach. The child derives 
no nourishment from its food, and in the end, if relief be not afforded, 
dies of exhaustion from starvation. 

In such cases, however, it is not uncommon to have a new train of 
secondary symptoms occur, such as heaviness, stupor, convulsions, &c. ; 
in fact, in all cases of prolonged disorder of the stomach or bowels, the 
most watchful attention should be directed to the condition of the 
nervous system, and the most prompt efforts made to relieve the earliest 
symptoms of disease of these organs. 

If relief be not afforded to this species of indigestion, the infant may 
linger on for five or six weeks, gradually become weaker, thinner, and 
more unable to digest its food, until at length it sinks from exhaustion 
or from some secondary attack. 

711. At the time of weaning, or soon after, the child is very apt to 
suffer from indigestion, in consequence of the change of food. This dis- 
order, however, is not confined to the stomach, but involves, apparently, 
the entire intestinal canal. It may come on a few days after weaning, 
or not for some weeks. Dr. Cheyne has given an admirable history of 
this disease under the term "Atrophia Ablactatorum." "The first 
symptom," he says, "is a purging, with a griping pain, in which the 
dejections are usually of a green color. When this purging is neglected, 
and, after continuing for some time, there is added a retching, with or 
without vomiting : when accompanied by vomiting, the matter brought 
up is frequently colored with bile. These increased and painful actions 
of the alimentary canal produce a loathing of every kind of food, and 
naturally are attended with emaciation and softness of the flesh, with 
restlessness, thirst, and fever. After some weeks I have often observed 
a hectic blush on the cheek; but the most characteristic symptom of this 
disease is a constant feverishness, the effect of increasing griping pain, 
expressed by the whine of the] child, but especially by the settled dis- 

1 Diseases of Children, p. 374. 



INDIGESTION. 491 

content of its features; and this expression of discontent is strengthened 
towards the conclusion of the disease, when the countenance has shared 
in the emaciation of the body. 

" In the progress of the disease the evacuations from the belly show 
very different actions of the intestines, and great changes in the biliary 
secretion ; for they are sometimes of a natural color, and at other times 
slimy and ash-colored, and sometimes lienteric. Towards the end of the 
disease the extremities swell, and the child becomes exceedingly drowsy; 
but these I rather conceive to arise from debility, than to be pathogno- 
monic symptoms. It is remarkable, in the advanced stages of the 
disease, that the purging sometimes ceases for a day or two, but with- 
out any amelioration of the bad symptoms ; nay, I think that children 
decay even faster than when the purging is most violent. The disease 
seldom proves fatal before the sixth or seventh week, and in this short 
time I have seen the finest children miserably wasted. I have seen, 
though rarely, a child recover after the disease had continued three or 
four months ; and again I have seen the disease cut short by death in 
the second, third, or fourth week, before it had reached the acme; the 
sudden termination having been occasioned by an incessant vomiting 
and purging, or by convulsions from the immense irritation in the 
bowels." 1 To this graphic description I have little to add, except that, 
in many instances, the symptoms of gastric disturbance precede those 
which indicate intestinal derangement, and which is the reason why I 
have introduced the disease here rather than under the head of diarrhoea. 
The disease, as Dr. Cheyne observes, is by no means rare, and, if neg- 
lected, is very fatal, but if taken in time is sufficiently manageable. It 
is more common with children who have been weaned abruptly, and at 
an unusually early period. 

712. At a later period, the child's stomach may become disordered, 
and an effort may be made for relief by vomiting or purging, or both, 
after which the child may resume its usual health. Or the derangement 
may continue, the appetite may be impaired, and the food taken appear 
to disagree with the stomach ; the child is pale, fretful, and uneasy, 
especially after a meal; complains of pain in the stomach and bowels, 
resembling colic or spasm ; is troubled with flatulence ; and occasionally 
the belly is swollen and tympanitic. 

The breath is sour, and there are acrid eructations, with repeated 
vomiting of undigested or half-digested matters, after which the child 
seems somewhat relieved. I have noticed the prevalence of this form 
of indigestion, somewhat modified in different cases, during the hot 
weather of summer. 

If this state of things continue, the intestinal canal becomes irritated, 
and purging sets in, and the evacuations are generally of a green color, 
accompanied by colic. The little patient is soon reduced in flesh and 
strength ; his countenance is pale and depressed ; his pulse weak, and 
sometimes quick ; the appetite diminished, and the animal spirits sunk. 
Occasionally the food passes through the bowels almost unchanged, con- 

1 Essay 2. On Bowel Complaints, p. 16. 



492 INDIGESTION. 

stituting the disease called lientery. In some cases the purging alter- 
nates with constipation. 

In process of time other organs become involved ; the liver gives 
evidence of functional disturbance ; but by far the most serious com- 
plication, and one by no means uncommon, is the head, as manifested 
by stupor, coma, or convulsions. This secondary affection, so common 
towards the end of gastric or intestinal diseases, places the patient in 
the greatest danger, from its occurring at a time when active treatment 
is nearly impossible, owing to the weak state of the child. No case 
requires greater watchfulness, none more judicious and skilful treat- 
ment, than these cases ; and, do what we may, a large proportion die. 

If no complication occur, the indigestion may often be cured, after 
an uncertain duration of from a week to a month; but it may also prove 
fatal from exhaustion. 

713. Morbid Anatomy. — As a general rule, post-mortem examina- 
tion reveals no trace of disease ; now and then, as Billard has observed, 
we may find vascular ramifications in the coats of the stomach; but this 
may be either the normal condition of the stomach with food in it, or 
a cadaveric change. Ordinarily the stomach and intestines are more 
bloodless than usual, semi-transparent, and unequally distended with 
air. The mucous membrane is pale throughout, and occasionally soft- 
ened. " The want of color," Dr. Stewart remarks, " is almost always 
the first degree of a species of softening, which should not be con- 
founded with a species of inflammation. The disease described by M. 
Cruveilhier, under the name of gelatiniform disorganization of the 
mucous membrane of infants, would appear, from the detail of symp- 
toms, to be a violent species of the disease now under consideration. 
M. Duges, in his Manuel d'Accouchemens, in speaking of a similar 
affection, remarks that he has found the interior coat of the intestines 
covered with a white mucus, of a pulpy consistence, and bearing a 
resemblance to imperfect chyle, and which inattentive observers might 
mistake for the softened mucous membrane. The mucous follicles, he 
observes, could be still seen on the intestinal surface." 1 

The post-mortem appearances in "weaning brash" are thus described 
by Dr. Cheyne: "I observed in every instance that the intestinal canal, 
from the stomach downward, abounded with singular contractions, and 
had in its course one or more intussusceptions; that the liver was exceed- 
ingly firm, larger than natural, and of a bright red color; and that the 
enlarged gall-bladder contained a dark green bile. In some dissections 
the mesenteric glands were swelled and inflamed ; in others, however, 
they were scarcely enlarged, and had no appearance of inflammation. 
These contractions and intussusceptions were entirely of a spasmodic 
nature, as, in the latter, the contained part of the gut was easily dis- 
engaged from that which formed its sac, and in no part of the entangle- 
ment was there adhesion or even the mark of inflammation ; and the 
contracted portions of the intestines were again permanently dilated by 
pushing the finger into them. These appearances lead me to imagine 
that weaning brash, in its confirmed state, is imputable to an increased 

1 Diseases of Children, p. 184. 



INDIGESTION. 493 

secretion of acrid bile, or rather to the morbid state of the liver which 
occasions this ; of which, however, I am afraid to attempt the explana- 
tion." 1 

714. Causes. — Before weaning, indigestion may be caused by excess 
in the quantity of milk, or by giving the child the breast too often, or 
too soon after vomiting, in order to quiet it. Deficiency or excess of 
the nutritive qualities of the milk, or its possessing bad or irritating 
qualities, may also give rise to it; and the latter condition may be 
caused by errors of diet on the part of the nurse, by her indolence, 
luxurious habits, giving way to passion, by the presence of the cata- 
menia, by the too great age of the milk, and by too prolonged nursing, 
as I have heretofore observed. 2 

The process of digestion may be disturbed, and the gastric powers 
deranged, by tossing or moving the child about, too soon after suckling. 

After weaning, the most common of all causes is some error in diet ; 
the child is fed too much or too frequently, or upon improper food; and 
when the stomach, with the admirable organic intelligence which it 
possesses in childhood, rejects what is not proper for it, instead of 
taking a hint, and giving it a change of food, or at least a rest, more 
food is given, and probably of the same kind, so that the stomach be- 
comes permanently deranged, and that which was a healthy process 
becomes a symptom of a morbid condition. 

Another cause, and doubtless a frequent one, is dentition. The sto- 
mach and bowels are very apt to be more or less disturbed during this 
process ; and, though distressing, it is the least injurious of all the 
reflex irritations to which dentition gives rise. It ceases, also, when 
the irritation is removed by scarification. 

Underwood and others have attributed this vomiting to the suppres- 
sion of accustomed discharges, or the sudden cure of cutaneous erup- 
tions. Dewees doubts this, but Eberle mentions a case in which the 
child was attacked by vomiting whenever a discharge from behind the 
ears was dried up, and which was relieved by reproducing it. 

715. Diagnosis. — The absence of permanent pain, tenderness, and 
fever, the weak, quiet pulse, and clean tongue, will generally suffice to 
distinguish this complaint from gastritis. The success or failure of the 
treatment will also throw some light upon the matter. 

But there are two other diseases with which it might be confounded 
at a certain period, and from which it is of the highest importance to 
distinguish it. Vomiting is often among the earliest symptoms of 
meningitis, at a period, indeed, when it sometimes requires a practised 
eye to detect more. But we may always find some nervous disorder, 
disturbed sleep, starting, staring, heaviness, flushed face, suffused eyes, 
headache, &c, none of which are remarkable in the present disease, and 
upon the presence or absence of which our decision must be made. 

Again, vomiting occurs in strangulated hernia, but a careful examin- 
ation, which in such cases, should never be omitted, will enable us to 
pronounce upon the presence or absence of the hernia. 

716. Treatment. — The first object is to regulate and correct the food 

1 Essay ii. p. 23. 2 Vide chap. iii. 



494 INDIGESTION. 

of the infant as to quantity and quality. If the disorder can be fairly 
traced to an excess of milk, of course it is easy to remedy that, and it 
should be done forthwith. But if, as is more frequently the case, we 
have reason to believe that the milk disagrees with the infant, the nurse 
should be changed, and a new one obtained, whose milk is of a suitable 
age. Nay, even if there be a doubt about it, it will be better to make 
the change. 

When satisfied about the nurse, I would advise that the infant should 
only be allowed to take half the usual amount of suck at a time, and 
have it oftener, if necessary, until the stomach recovers its tone. 

If the bowels be confined, they should immediately be freed by an 
enema, as their action tends to quiet the stomach. 

I have found nothing so effectual in tranquillizing the gastrointes- 
tinal disturbance as the following mixture : 

R — Mist, amygdal., 

Aquse carui, ilil ^ss. 

Spts. ammon. arom. gutt v. 

Tincturce opii, gutt. ij. vel. iij. — M. 

A teaspoonful may be given, two, three, or four times a day, and at 
the same time some counter-irritant should be applied over the stomach: 
either a poultice of mustard and linseed-meal, a liniment containing a 
small quantity of laudanum, or a small blister. 

Dr. Eberle recommends small doses of calomel and ipecacuanha. " I 
have repeatedly succeeded in arresting vomiting," he says, "from in- 
ordinate gastric irritability in infants, by exhibiting the eighth of a 
grain of calomel, with one-sixth of a grain of ipecacuanha, every hour 
or two, in conjunction with the application of a stimulating poultice or 
plaster over the epigastrim." 1 In obstinate cases he advises "a grain 
or two of morphia to be sprinkled on the surface of a small plaster of 
common cerate, and laid over the pit of the stomach." Dr. Stewart 
speaks highly of rhubarb and ipecacuanha. 

Dr. Underwood says, "a drop or two of the aqua kali, or a little 
Castile or almond soap, are excellent remedies, not only as they will 
correct acidity, but promote the secretion of bile, as well as a generous 
warmth in the great passages, and assist the digestion. For which pur- 
pose, also, myrrh is an excellent remedy, when infants are a few months 
old." 2 

The gums should be carefully examined, and a free incision made, if 
there be the least evidence of irritation from the teeth. 

717. Dr. Cheyne recommends that in the beginning of "weaning 
brash," when the attack is slight, we should give a dose or two of rhu- 
barb, at intervals of two days, and a half or third of a grain of ipecacu- 
anha, with six or eight of prepared chalk, and some aromatic powder, 
every four or five hours. If there be much griping, an anodyne enema 
may be given. The diet must also be regulated carefully, and animal 
substances are better than vegetable. Eggs, fine ship biscuit, arrow- 
root custard, the juice of lean meat, plain animal jellies, and milk, are 

1 Diseases of Children, p. 210. 2 Diseases of Children, p. 225. 



INDIGESTION. 495 

the chief articles of nourishment. A wet-nurse would undoubtedly be 
the best, if the child were young and would take the breast; and the 
best substitute I have found for this is ass's milk. 

In the severe cases, Dr. Cheyne found more benefit from half a grain 
of calomel twice a day for some time, with anodyne enemata for the 
relief of the pain, than from anything else. 

718. When the child is still older, if his stomach have been over- 
loaded, or if he have taken indigestible food, it will be well to commence 
with an emetic, after which we may have recourse to small doses of 
laudanum, with or without ammonia, and external irritation. The 
bowels must also be kept free, but if diarrhoea be present, with much 
pain, an anodyne enema may be administered. If there be any evi- 
dence of biliary derangement, small doses of calomel, or hyd. c. creta\ 
will be very useful, followed occasionally by a purgative, or combined 
with an astringent, according to the state of the bowels. 

With children of three or four years old, I have succeeded very well 
by combining an alkali with some vegetable bitter, after the irritable 
state of the bowels has been relieved. 

Carbonate of soda, magnesia, or lime-water and milk, may be given 
if there be an excess of acid in the stomach, and the dilute muriatic 
acid, or lemonade, if there be a deficiency. Dr. Condie speaks very 
highly of a combination of magnesia, extract of hyoscyamus, calomel, 
and ipecacuanha ; and also of a few drops of spirits of turpentine, or 
the ethereal solution of camphor. External irritation, by mustard lini- 
ment or blister, is of great use; and if there be colic, laudanum may be 
applied externally as well as internally. Sometimes great relief is 
afforded by fomentations, or by a large linseed poultice to the belly. 
When the disease has been arrested, tonics may be necessary. I have 
found great benefit from two or three grains of carbonate of soda, and 
as much powdered columba, three times a day. 

" In that form of infantile indigestion in Avhich softening of the 
stomach is most likely to occur, a trial may be made of hydrochloride 
of iron, which appears to have frequently succeeded in restoring the 
healthy functions of the stomach in the hands of Pommer, Herzt, Cam- 
merer, Droste, and others." 1 

The diet must be carefully regulated, and it is far better to retrograde 
a little, and substitute a simpler diet than the one to which the child 
has been used. Milk, eggs, arrowroot, panada, &c, will answer better 
than animal food. 

719. When the head is becoming involved, no time must be lost in 
making the best use we can of derivatives and counter-irritants. Mus- 
tard cataplasms or blisters to the legs, blisters to the head or neck, 
cold lotions to the head, &c, must be tried in succession. In few cases 
can we venture to take blood or apply leeches, and yet the disease must 
be checked quickly if the child is to live. Meantime, the treatment 
for the primary complaint must go on, except, perhaps, a more sparing 
use of laudanum. 

If the child be greatly reduced, more nourishment must be given ; 

1 Condie on Diseases of Children, p. 203. 



496 GASTRITIS. 

jellies, broths, or beef-tea will be necessary, and sometimes wine whey ; 
nor have I found the head symptoms increased by it, but frequently 
lessened as the extreme exhaustion was relieved. 



CHAPTER XV. 

GASTRITIS. — INFLAMMATION AND SOFTENING OF THE STOMACH. 

720. Inflammation of the stomach and its consequences have not 
received very much attention from authors, until comparatively recent 
times, although it is probable that some of the cases described under 
the term "vomiting" were really of this nature. Saillant, 1 Fleisch, 2 
Lesser, Maunsell and Evanson, 3 and others, have noticed the disease ; 
but we are more indebted to Dunglison, 4 Billard, Stewart, Condie, 
Rilliet and Barthez, &c. Jaeger, 5 Camerer, Morgagni, Sandifort, and 
Hunter, described a softening occurring at the larger extremity of the 
stomach ; and since their time Ramisch, 6 Vogel, Hufeland, Cruveil- 
hier, 7 Billard, Bouchut, Barrier, Rilliet and Barthez, &c, have thrown 
much light upon the subject, although there are still questions left un- 
decided. 

Inflammation of the stomach is by no means a frequent disease, nor 
is it always so well marked as to enable us to distinguish easily between 
it and functional disorder, such as I described in the last chapter ; and 
moreover, it is frequently combined with irritation or inflammation of 
the intestines. It may be either primary or secondary, but, according 
to Rilliet and Barthez, far more frequently the latter than the former. 

721. Symptoms. — The symptoms are not always very characteristic, 
and in some cases are very obscure. In certain cases Rilliet and Bar- 
thez remark that the disease is completely latent, revealing itself by 
no symptom, or by some trifling phenomenon which escapes notice ; as 
for example, one or two vomitings after medicine containing tartar emetic 
or ipecacuanha; or vomiting, apparently sympathetic, at the commence- 
ment of the primary malady. Among these cases we find erythema- 
tous, pseudo-membranous, or ulcerated gastritis, and above all, softening 
of the stomach." 8 

Ordinarily, however, as M. Saillant observes, the child complains of 
more or less pain, often very severe, occurring in paroxysms at short 
intervals, with violent contortions of the body. Vomiting is a common 
occurrence, both at the beginning and during the course of the disease, 

• Me"m. de la Soc. de Med. 1786, p. 327. 

2 Die Entziindung, &c, p. 230. 3 Diseases of Children, p. 277. 

4 On Diseases of the Stomach and Bowels in Children, 1824, p. 180. 

5 Hufeland's Journal, May, 1811, and Jan. 1813. 

6 Aug. Lit. Zietung, No. 56, May, 1S26, p. 447. 

7 Anat. Path., Livraisons 4-7, &c. 

8 Mai. des. Enfans, vol. i. p. 405. 



GASTRITIS. 497 

though there may be considerable intervals. The matters ejected are, 
first, the ingesta, then a greenish or yellowish fluid, and, in some rare 
cases, according to Denis, 1 blood. We must, however, be careful, if 
the infant be at the breast, not to mistake the source of the blood, 
which may have been drawn from the mother's nipple. In some of the 
worst cases the vomiting is excessive as to quantity, and incessant. 
Rilliet and Barthez have remarked that the vomiting is more trouble- 
some when softening occurs, than in simple gastritis, although there is 
often a sudden and complete cessation for some time before death. 

The bowels may or may not be disturbed. In some cases there is 
rather obstinate constipation; in others, and more frequently, there is 
diarrhoea. The abdomen is generally swollen and tympanitic; the 
epigastrium hot, tense, and tender on pressure; the thirst great ; the 
appetite lost ; the tongue sometimes loaded and white, sometimes dry 
and red at the point and edges. The urine is generally scanty : the 
pulse is quick and small, but not weak; the skin hot and dry. 

Thus, then, the principal symptoms are the heat, tension, pain, and 
tenderness of the epigastrium, with vomiting, and a quick pulse and 
fever. 

722. But the attack "may become chronic and continue for a length 
of time, with occasional vomiting, some degree of tension and tender- 
ness of the epigastrium, irregular appetite, occasional diarrhoea alter- 
nating with costiveness, a dry and harsh condition of the surface, 
febrile symptoms of a remittent character, and progressive emaciation. 
White softening of the stomach, with perforation, may occur in these 
cases; or, the irritation being transmitted to the brain, effusion into that 
organ may take place ; or, tubercles becoming developed in the lungs, 
the patient may die with all the symptoms of tubercular phthisis." 2 

723. Inflammation of the stomach may result in softening, ulcera- 
tion, or gangrene. I do not know that there are any symptoms by 
which we may detect the two latter occurrences during life. Under 
the title "gelatinous softening," M. Gruveilhier has described a well- 
marked disease ; and more than once Billard has seen an accurate diag- 
nosis made by M. Baron. M. Billard thus enumerates the symptoms: 
"The disease usually commences with symptoms of violent gastritis, 
such as tension and pain in the epigastric region ; the substances 
discharged by vomiting are not only the milk and drinks, but yellow 
and green fluids, occurring either immediately or long after eating or 
drinking. There sometimes exists a diarrhoea, varying in different 
subjects. It will return after having ceased for one or two days. The 
stools are often green, like the matters discharged by vomiting. The 
skin is cold at the extremities ; the pulse, generally irregular, is how- 
ever, very inconstant; the face continually expresses pain, and is 
wrinkled, as if the child were crying ; the cry is painful, and the respi- 
ration jerking, and the general restlessness induces a belief of the 
existence of a cerebral affection. To these symptoms succeed a general 
state of prostration and insensibility, occasionally disturbed by a return 

1 Mai. des Enfans Nouveaux-n£s, p. 46. 

2 Condie on Diseases of Children, p. 204. 

32 



498 GASTRITIS. 

of pain, producing from time to time the same restlessness which 
appeared at the commencement of the disease; and lastly, at the end 
of six, eight, or fifteen days, and sometimes later, the patient sinks, 
wasted by wakefulness, continual vomiting, and pain. In very young 
infants scarcely any fever is manifested in the midst of this disorder. 
When the disease is chronic, the progress of the symptoms is slower." 1 

724. Morbid Anatomy. — On post-mortem examination, the stomach 
exhibits the different modifications of inflammatory action I have recently 
noticed. 1. There may be found a diffused redness in some parts, or it 
may extend in bands or lines along the longitudinal folds, or in 
vascular ramifications; such is the erythematous gastritis. 2. Or we 
may discover in some portion of the stomach a pseudo-membranous 
secretion, analogous to that in muguet. 3. The follicular glands may 
be chiefly affected, enlarged, prominent, and ulcerated. 4/ The in- 
flammation may have terminated in gangrene with general disorgani- 
zation of the tissues, or a limited disorganization resembling an eschar. 2 
5. The mucous membrane, or all the tissues of the stomach, may be 
softened. 

725. But a little more detail is necessary touching this "ramollisse- 
ment gelatiniforme," which is thus described by M. Cruveilhier: " This 
softening always proceeds from the interior towards the exterior. 
There is at the beginning simple separation of the fibres by a gelatinous 
mucus, and in consequence the parietes are thickened and semi-transpa- 
rent. Shortly after, the fibres themselves are involved and disappear, 
so that the softened stomach or intestine resembles transparent gelatin 
in the form of a tube or a portion of a tube. If the transformation be 
complete, the disorganized portions are removed, layer after layer, those 
which remain becoming gradually thinner. The peritoneum alone resists 
for some time, but at length it is attacked, worn, and gives way, and 
perforation of the stomach results. The parts thus transformed are 
colorless, transparent, apparently inorganic, completely deprived of 
vessels, and exhaling an odor resembling that of milk. The softened 
portions are decomposed much less quickly than the unaltered portions. 
Boiling, which converts the stomach and intestines into a jelly, gives a 
perfect idea of this morbid alteration." 3 

M. Billard has described two forms; the first, answering pretty accu- 
rately to the above description of M. Cruveilhier, he regards as patho- 
logical, but not the second species, in which the gastric tissues are simply 
deprived of color and softened. 

The great pathological questions connected with this morbid change 
are: 1. Is it a pathological or cadaveric change? 2. If pathological, 
is it the result of inflammation or a disease sui generis? 

M. Valleix says : " It seems to me impossible, in the present state 
of science, to distinguish, during life, the cases of simple pale softening 
with thinning, from those in which the softening is associated with 
evident traces of inflammation;" 4 and further on he gives his opinion 

1 Mai. des Enfans, Stewart's trans., p. 267. 

2 Rillet and Barthez, Mai. des Enfans, vol. i. p. 459. Denis, Mai. des Nouveaux-ne"s, 
p. 56. 

3 Anat., Path., livr. 4-7, &c. 4 Guide de Med. Prat., vol. v. p. 188. 



GASTRITIS. 499 

that it is the result, either pathological or cadaveric, of chronic 
gastritis. 

M. Billard observes : " What inference shall be drawn from the pre- 
ceding facts and considerations ? That the gelatinous softening of the 
stomach consists in a disorganization of the mucous membrane of this 
organ, caused by intense inflammation, acute or chronic ; that this dis- 
organization is characterized by an accumulation of serosity in the walls 
of the organ, a swelling and gelatinous consistence of the mucous mem- 
brane at a part usually circumscribed, situated generally in the larger 
curvature of the organ, and round which there are more or less evident 
traces of acute or chronic inflammation ; that this disorganization 
entails others, may give rise to spontaneous perforation causing speedy 
death ; and that it may be developed not only at the period of the first 
dentition, as in most of M. Cruveilhier's cases, but even in very young 
infants, of which I have reported examples." 1 

Rilliet and Barthez regard this as, a secondary lesion, and as most 
likely the result of inflammatory action. 

M. Bouchut denies that it is an isolated disease, but a consequence of 
the acidity of the fluids contained in the digestive canal. 2 

Jaeger, Camerer, and Zeller refer it to a paralysis of the nerves of 
the stomach, with increased acidity of the gastric juice. 

Cruveilhier and Bokitansky admit two kinds of softening, one patho- 
logical, the other cadaveric. 

Rokitansky conceives that the softening of the stomach in children 
is pathological, and dependent upon a disease which he regards as almost 
peculiar to early life. 

M. Barrier differs from those who regard it as a specific disease ; he 
thinks it most frequently cadaveric and chemical, but, if pathological, 
that it is the result of an anterior morbid condition. 3 

Dr. Dunglison considers that there is little difficulty in pronouncing 
it the result of previous inflammation. 4 

Dr. Carswell agrees that it may be either cadaveric or pathological ; 
and that when it is the latter, the symptoms are those of gastritis or 
enteritis ; and he adds, that there are no symptoms referable to the 
state of softening which we have described, considered in itself, and as 
a termination of inflammation of the mucous membrane." 5 

Dr. Stewart regards this softening, as well as the other morbid 
changes, to be the result of inflammation. 6 

Dr. Condie remarks : " Without denying that the stomach may be 
dissolved after death, in consequence of the generation in its cavity of 
an excess of acid ; and being well aware that a softening of the tissues 
of the stomach and of other parts of the alimentary canal may be pro- 
duced by causes affecting the nutrition, and impairing the cohesion of 
the various tissues, altogether independent of inflammation, we are still 
convinced, from the result of our own observations, that the gelatinous 
softening, so frequently observed in children who have died of acute 

1 Mai. des Enfatis Nouveaux-nes, &c, p. 232. 

2 Mai. des Enfans Nouveaux-n6s, p. 231. 3 Mai. de PEnfance, vol. ii. p. 118. 

4 Diseases of Stomach and Bowels, p. 183. 

5 Cyclop, of Pract. Med., toI. iv. pp. 13-15. 6 Diseases of Children, p. 249. 



500 GASTRITIS. 

gastritis, is invariably the effect of intense inflammation of the mucous 
and other tissues of the stomach." 1 

Dr. West "has not been able to discover any peculiarity in the cha- 
racter of such symptoms (of disordered functions), nor even any con- 
stancy in their occurrence ; nor have I observed that the disease of 
which the infant died has exercised any appreciable influence in predis- 
posing to softening of the stomach, or in preventing its occurrence." 2 

Dr. West also mentions a recent theory of Dr. Elsasser. 3 " He refers 
the alteration of the tissues not to the gastric juice itself, but to the 
acids generated during the decomposition of the food contained within 
the stomach and intestines at the time of death, and endeavors to 
account for the frequency of the occurrence in the case of infants, from 
the facility with which a free acid is generated in the milk which forms 
the chief part of their sustenance. According to his researches, which 
appear to have been carefully conducted, the change never ought to 
take place when the stomach is empty, but his assertion that it never 
does is opposed to universal experience." 4 Further, the same excellent 
writer mentions, that in Herrich and Popp's work 5 there is " a table of 
104 cases in which softening of the stomach was found after death from 
different causes and at various ages. In no instance were symptoms 
observed that would have enabled any one to pronounce, beforehand, 
that softening of the stomach would be discovered after death. In by 
far the greater number of cases the stomach was empty, showing that 
the cause was very often independent of digestion ; while the period of 
childhood, the rapid course of the fatal disease, and death from cerebral 
affections, were the only circumstances that appeared to have any clearly 
appreciable influence in favoring its production." 

It appears, then, that redness with thickening or softening, or both, 
are undoubted proofs of inflammation ; that false membrane, ulceration, 
and gangrene are equally conclusive evidence of previous or accompany- 
ing gastritis ; but that pale, gelatiniform softening may be either the 
result of disease or a change which takes place after death. The ba- 
lance of evidence is in favor of one at least of the forms of this curious 
alteration of structure being the result of inflammation, but the cause 
of the other is uncertain. 

726 Causes. — Gastritis may arise from the continued use of improper 
food converting the indigestion described in the last chapter into actual 
inflammation, or from eating acrid substances, or swallowing poisonous 
matters. Nay, more, it would appear from the observations of Rilliet 
and Barthez that the continued use of powerful remedies, such as tartar 
emetic and croton oil, in secondary affections, gave rise to gastritis, 
even though the dose were moderate. Although these medicines are 
valuable, and in some cases necessary, still this should be a warning to 
use great care and watchfulness in their administration. 

As a general rule, I have not found one sex more liable to the dis- 
ease than the other; but of thirty-one cases of gastritis, observed by 

1 Diseases of Children, p. 206. 2 Diseases of Infancy and Childhood, p. 366. 

3 Die Magenei-weichung der Saiiglinge, Stutgard, 1816. 

4 Diseases of Infancy and Childhood, p. 366. 

6 Der plotzlichen Tod, aus inneren Ursachen, p. 330. 



GASTRITIS. 501 

Rilliet and Barthez, twenty-three were boys, and eight girls ; and of 
twenty-seven cases of softening, fourteen were boys, and thirteen girls. 
The latter was much more frequent before the age of six than after- 
wards; the former nearly equal at all ages. Children of weak constitu- 
tions, or who have been exhausted by disease, seem more liable to the 
complaint. 

The usual exciting causes, cold, damp, exposure, bad food, crowding, 
&c, may influence the production of this disease as well as others; but 
we find that it is frequent as a secondary affection, and the principal 
diseases in the course or towards the termination of which it occurs are, 
meningitis, meningeal apoplexy, pneumonia, and the eruptive fevers. 
In many cases, particularly in young infants, the inflammation of the 
stomach is preceded by an attack of stomatitis; in others the stomatitis 
occurs subsequently to the gastritis. 

727. Diagnosis. — The most characteristic symptoms of gastritis are, 
pain, heat, tenderness and tension of the epigastrium, with vomiting; 
and when these are present we can have no doubt of the nature of the 
attack, nor any difficulty in distinguishing it from the indigestion I 
described in the last chapter ; but in many cases these symptoms are 
less marked, and in some they are absent ; and then, undoubtedly, it 
will be difficult, if not impossible, to arrive at any certainty. 

We have already seen, on the highest authority, that there are no 
symptoms which indicate the occurrence of softening. 

728. Treatment. — The first indication is, of course, to remove every 
possible cause. If the child be young, it will be well to change the 
nurse, or, if older, to substitute some bland, easily digested food for 
that it has been habitually using. 

If it be teething, the gums must be lanced freely ; and if the bowels 
are confined, a purgative enema should be given at once. 

If the symptoms of gastritis should occur during the treatment of 
another disease, we must, of course, give up the use of all powerful and 
irritating medicines, and seek to accomplish our object in some other 
way. 

Should the patient be tolerably strong, and the gastritis primary, or 
if secondary and the child not much reduced, it will be advisable to 
apply a few leeches to the epigastrium, limiting the amount of the bleed- 
ing, and, after that has stopped, applying a light, warm, linseed-meal 
poultice. 

If, however, the child cannot bear this, or if partial relief only be 
obtained by it, some irritating application will be advisable — a pretty 
strong liniment, mustard poultice, or a blister. I am inclined to think 
that the latter is, on the whole, less painful, as well as more effectual. 
Great advantage is sometimes derived from dressing the blistered sur- 
face with ointment in which there is a small quantity of opium or mor- 
phia. 

M. Billard advises the tartar emetic ointment; but I should hesitate 
to use this, on account of the gastric irritation it sometimes occasions, 
even when applied externally. 

The more distressing symptoms, vomiting, heat at the epigastrium) 



502 GASTRITIS. 

&c, may often be soothed by very cold drinks, or by a small fragment 
of ice swallowed now and then. 

There is no great choice of internal medicines: a minute dose of calo- 
mel, or the hyd. c. cretS, two or three times a day, with a little chalk 
and opium, or Dover's powder, will be useful. Or we may order a mix- 
ture with mucilage, syrup, and spearmint water, and one, two, or three 
drops of laudanum to the ounce, of which a teaspoonful may be taken 
three or four times a day. 

Dr. Condie gives from one-sixth to one-half of a grain of calomel 
every one or two hours. " This we have known," he says, "in a large 
number of cases, to suspend very promptly the irritability of the sto- 
mach, and to produce a favorable change in the symptoms generally. 
In cases attended with frequent, thin, acid evacuations from the bowels, 
the calomel we have found very generally to arrest the diarrhoea and 
render the stools of a more consistent and natural appearance. We 
ordinarily combine with each dose of the calomel a grain or two of cal- 
cined magnesia, and give it mixed in a little mucilage; but when there 
exists \erj great irritability of the stomach, we direct the calomel, 
combined with a few grains of powdered gum acacia, to be placed dry 
upon the tongue, the child being shortly afterwards given to drink a 
spoonful of thin mucilage." 1 

The diet must be carefully arranged — simple, bland, and unirritating 
it ought to be. Milk in any form, milk and lime-water, mucilage, 
blanc-mange, arrowroot, tapioca, sago, &c, may be used according to 
the age of the child. After weaning, I have found ass's milk a very 
nice substitute for cow's milk. But the quantity is as important as the 
quality ; it will be quite necessary to diminish the usual amount, nay, 
in some cases, to give only what is necessary to support life. 

7:29. There is no special treatment for softening of the stomach; the 
remedies employed for the gastritis, if they are successful, will super- 
sede the necessity of others for the ramollissement, and if they fail we 
have none other more effectual. Rilliet and Barthez recommend chiefly 
the gummy extract of opium, or if this cannot be given internally, mu- 
riate of morphia is to be sprinkled over a small blistered surface at the 
epigastrium. 

Dr. Lion, of Breslau, depends principally upon external means and 
a suitable diet, very small quantities of food at a time, a warm bath, 
mild enemata, exercise in the open air, an aromatic plaster to the sto- 
mach, and internally the decoction of acorns, carbonate of iron, or the 
tinct. ferri muriatis. 2 

Chronic gastritis may be treated by nearly the same means ; leeches 
will not be necessary, but small and repeated blistering will be most 
advantageous, with a warm bath occasionally, and mild unirritating 
diet. Dr. Condie speaks highly of a combination of calomel, ipecacu- 
anha, and hyoscyamus. The state of the bowels must be carefully regu- 
lated. 

' Diseases of Children, p. 207. 

2 Ranking's Abstract, vol. i. p. 177, from Casper's Wochenschrift, No. 34. 



DIARRHCEA. 503 



CHAPTER XVI. 



DIARRHCEA. — CHOLERA INFANTUM. — ENTERITIS. 

730. There is no complaint so common in infancy and childhood as 
disordered bowels, and this we can easily understand, on account of the 
delicacy of the mucous membrane, and the novelty, so to speak, of the 
functions it is called upon to fulfil, in the first instance ; and the variety 
and irregularity, both of quantity and quality, of the food submitted to 
it in after years of childhood, to say nothing of the reflex disturbances 
arising from irritation of other organs, and of which this is the most 
frequent seat. 

This disorder of the bowels varies in extent, intensity, and results, 
in every possible way. In some there is merely an increased looseness, 
temporary, and without any ill effects ; in others the purging continues 
long, with some inroads upon the constitution, but without any deviation 
from the normal condition of the discharges. Again, the quantity of 
the discharges may not only be increased, but' the quality may be very 
much changed, indicating in some cases a more extensive, in others a 
more serious morbid action ; and, lastly, this disordered function may 
be accompanied with symptoms which indicate the presence of inflam- 
mation, whose actual existence may be proved after death. And yet it 
is often very difficult to draw the line between functional disturbance 
and organic disease. The symptoms may be identical, or nearly so, 
and the results may be analogous. I have, therefore, thought it better 
to include all in the one chapter, noting, so far as I am able, the grada- 
tions and the symptoms significant of each. 

Let me remark, also, that although for the convenience of descrip- 
tion, gastritis, enteritis, and colitis are treated separately, yet we more 
frequently find them conjoined in practice, as gastro-enteritis or entero- 
colitis, than isolated, as the reader will find them in books. This is an 
inconvenience which cannot be altogether avoided. 

Diarrhoea, then, whether functional or the result of inflammation, 1 
may be either acute or chronic, either primary or secondary. 

731. Symptoms. — Dewees, Eberle, and others have classified diar- 

1 M. Billard divides the disease into erythematous gastritis, with or without altera- 
tion of secretion, follicular enteritis, and enteritis properly so called. M. Valleix de- 
scribes simple enteritis, and enteritis combined with muguet. Rilliet and Barthez treat 
all varieties under the title of gastro-intestinal inflammation. M. Barrier speaks of 
acescent, follicular, serous, flatulent, and verminous diacrisis. M. Bouchut and Dr. 
West made a division into: 1, catarrhal diarrhoea; 2, inflammatory diarrhoea. M. 
Trousseau divides the diarrhoea of infants into four species: 1, bilious; 2, mucous; 3, 
lienteric; and 4, choleriform diarrhoea, or cholera infantilis. M. Legendre regards the 
majority of cases as alterations of secretion, and the morbid lesions rather as their conse- 
quence than their cause. 



504 DIARRHCEA. 

rhcea, according to the character of the discharges, in the following 
manner : — 

I. Feculent Diarrhoea, in which the discharges are increased in quan- 
tity and frequency, but preserve their natural character, the evacuations 
being preceded by slight nausea, and accompanied with some pain. 

ir. Bilious Diarrhoea. — '* In this species the fseces are loose, copious, 
and of a bright yellow or green, and the bowels are stimulated to inor- 
dinate action by an overcharge of bile, either vitiated or not. This 
complaint is very frequent among our children during the heat of our 
summer, or as the fall approaches. The influence of a hot sun upon 
the action of the liver is well known to everybody. It is familiar to 
common observation that after a spell of very warm weather even the 
healthy evacuations of the adult give evidence of its rapid formation, 
and sometimes of its abundant absorption. Thus the feces are observed 
to be loaded with bile, and the urine to be deeply tinged with it ; and 
when the complaint of which we are treating seizes upon children, it is 
called the 'liver complaint.' 

" This action of the bowels, as in the species just considered, some- 
times relieves them of their stimulating contents, and will thus effect its 
own cure ; hence this species, like the others, may be ephemeral, and 
not be more formidable than the feculent species, unless the formation 
of bile goes on almost indefinitely, or fever be provoked." 1 

nr. Mucous Diarrhoea. — The evacuations in this variety contain a 
considerable amount of mucus, or may perhaps consist almost entirely 
of it. The discharge may not be very frequent nor very large ; there 
is generally some little tenesmus, and occasionally a little blood. Ordi- 
narily, their color is greenish, or light green, and very offensive. Some- 
times they resemble chopped spinach ; at other times yellowish or green- 
ish clay, with a very bad odor. 2 Dr. Graves regards this green matter as 
a secretion from the mucous membrane of the small intestines, and not 
bile. Drs. Simon and Golding Bird 3 consider it owing to blood which 
has undergone a chemical change. In common with the latter physician, 
I have observed that in many cases these green stools are originally 
yellow, but become quite green in an hour or two. The mucus is at first 
thin and transparent ; afterwards it becomes thicker, opaque, and almost 
puriform. This form appears to arise from sudden transitions of the 
weather, or from a sudden chill. 

IV. Chylous Diarrhoea. — In this form the discharges are whitish or 
milky. There appears to be rather a deficient secretion of bile, than 
any obstruction to its escape, as it is never attended by jaundice. This 
milky fluid is supposed by some to be chyle, and Dr. Dewees asks why 
the lacteals do not absorb it ? and he debates whether this arises from 
their incapacity or from the badly concocted nature of the chyle. Might 
it not be well to precede these by another question — whether this fluid 
be chyle at all, and not rather a morbid secretion from the intestines ? — 
which I am inclined to believe. 

1 Dewees, Diseases of Children, pp. 381-2. 

2 Hamilton, Management of Infants, p. 69. 

3 Med. Gazette, Sept. 1845. 



DIARRIKEA. 505 

A child thus attacked becomes rapidly weak and emaciated, and, if 
not soon relieved, sinks from exhaustion. 

V. Lienteric Diarrhoea. — This is characterized by the transit of the 
food nearly unchanged through the alimentary canal. It sometimes 
follows some of the other species, but more frequently dysentery. The 
child is uneasy after eating, and soon has a desire to go to stool, when 
it passes the food taken shortly before. " It generally," says Dewees, 
" commences during the chronic state of diarrhoea, by showing, perhaps, 
that some one article of diet only has passed the bowels unchanged, as 
potato, apple, or other vegetable substance or fruit, which has been 
incautiously given to the child. This is pretty soon followed by other 
articles, as meat, &c, and finally everything almost that enters the 
stomach is speedily conveyed through the intestines, with little or no 
appearance of having been acted upon by the powers of the stomach. 
The appetite is sometimes voracious in this disease, and the thirst is 
always considerable." 1 

Dr. Mason Good thinks that there is a deficiency of biliary secretion, 
as in the last variety ; but with this opinion Dr. Dewees' opinion does 
not agree : he considers that the "complaint is seated altogether in the 
stomach itself, and owes its existence to the too great irritability of this 
organ; for no sooner is food lodged in it, than it makes efforts by an 
increased peristaltic action to discharge it, and the intestines transmit it 
with equal speed to their extremity, there to be discharged." 2 

732. So much for the varieties of the evacuations of diarrhoea. The 
other symptoms will vary in different cases, but not altogether according 
to the peculiar discharge. There is generally a certain amount of 
uneasiness and pain ; sometimes this is very considerable, accompanied 
by rumbling in the bowels, and an escape of flatus. 

There is often considerable tenesmus and forcing, so that the child is 
very unwilling to cease its efforts, and these are sufficient in many cases 
to cause a troublesome prolapse of the anus. This seems to be the result 
of relaxation of the sphincter ani, from the frequent discharges, and the 
violent forcing efforts made by the child. When once it occurs, it is 
generally reproduced with each evacuation, and may degenerate into a 
habit that will persist after the diarrhoea is relieved. 

If the discharge be considerable, the child is rapidly reduced in flesh, 
and in young infants the muscular substance becomes quite soft and 
flabby. It is also much Aveakened, so as not to be able to run about or 
walk without great fatigue. There is an expression of weariness, de- 
pression, and sinking about the face, in some cases resembling collapse, 
until reaction takes place. The eyes are sunk, surrounded by dark 
circles, the features are sharpened, and in prolonged cases the child 
acquires an appearance of age. The tongue may be either white and 
coated, or red, and occasionally there is a curdy matter, something like 
the commencement of muguet. The thirst is greatly increased, some- 
times quite intense, with great dryness of the mouth. 

At first the pulse is but little altered, but if the disease continue long 
and severe it becomes very quick and small, with hot skin and other 

i Diseases of Children, p. 391. s Ibid., p. 392. 



506 CHOLERA INFANTUM. 

evidences of fever. The abdomen is rarely tender, on pressure, but it 
is sometimes distended by flatus ; more frequently, I think, at least in 
the earlier stages, it appears shrunk, concave, and empty. 

In some cases we find a sudden collapse, resembling that of cholera, 
after which the child rapidly sinks, unless reaction can quickly be 
produced. 

CHOLERA INFANTUM. 

733. There is, however, another variety of diarrhoea which I must 
notice, and which seems to be far more frequent in America than in 
these countries. It is not, however, limited to America, but is common 
in other warm climates. The reader will find most valuable informa- 
tion upon this disease in the essays of Dr. Rush (1789), Dr. Miller 
(1800), Dr. James Mann (1805), Dr. Jackson and Dr. Horner (1829), 
and in the excellent treatises of Dewees, Eberle, Stewart, and Condie. 

It appears more common in the Southern and Western States, during 
the months of July, August, and September, and chiefly in the cities. 
In Philadelphia it is more frequent than in New York or Boston : " In 
the latter city it has been doubted whether the disease exists in its 
genuine form." " In Philadelphia, during a period of ten years, from 
1835 to 1844, inclusive, 2583 infants perished from this complaint, 
being nearly 11 per cent, of the whole number of infants under five 
years of age who died during that period, and 5.3 per cent, of the entire 
mortality of the city." Dr. Condie further remarks that "the dis- 
ease occurs as an endemic in all the large cities throughout the Middle 
and Southern and most of the Western States, during the season of the 
greatest heats, making its appearance and ceasing earlier. or later, ac- 
cording as the summer varies in the period of its commencement and 
close. Thus in Pennsylvania, Maryland, and Virginia, Kentucky and 
Ohio, it commences sometimes early in the month of June, and con- 
tinues until October, prevailing to the greatest extent in July and 
August, whilst in the more southern States it appears as early as April 
or May, and frequently cases of it occur until late in November. Its 
only subjects are infants, chiefly those between four and twenty months 
of age, seldom attacking them younger or older, being commonly con- 
fined to the period of the first dentition. So generally is this the case, 
that an infant's second summer is considered by mothers as one of un- 
usual peril ; and should it escape at that age an attack of cholera, or 
pass safely through the disease, it is considered to have a fair chance of 
surviving the period of infancy." 1 

In Massachusetts, in five years from 1844 to '48, inclusive, there 
were 852 deaths from this disease, and in Baltimore it was epidemic in 
1848. 

1 Diseases of Children, p. 233. During the present epidemic of Asiatic cholera (1849), 
my friends Drs. Asken and O'Reilly inform me that the proportion of children under five 
years of age admitted into two of the hospitals is in the proportion of 1 child to 25h 
adults, as follows : Brunswick Street Hospital — -total number of cases, 407. Children, 
males, 4 ; females, 8. Died, males, 1 ; females, 4. Cured, males, 3 ; females, 4. Green 
Street' Hospital — total number of cases, 797. Children, males, 15 ; females, 16. Died, 
males, 7; females, 12. Cured, 12. 



CHOLERA INFANTUM. 507 

734. The disease is often preceded by diarrhoea, but in the majority 
of cases, according to Eberle, the vomiting and. purging commence to- 
gether, with no other premonitory symptoms than languor, fretfulness, 
loss of appetite, or a morbid craving for food. In -whatever way it 
commences, however, the characteristic vomiting and purging soon 
appear, with great prostration, emaciation, and sinking. 

From the beginning the pulse is quick, small, and somewhat tense. 
The tongue is covered with a slight white fur at first, but as the disease 
advances this may disappear, and the tongue assume a bright, dry, and 
polished appearance. 

" At first the discharges from the bowels usually consist of a turbid, 
frothy fluid, mixed with small portions of green bile, or of a nearly 
colorless water, containing small flocculi of mucus. After the disease 
is fully developed, the evacuations very rarely exhibit any traces of 
bilious matter, the biliary secretion being evidently entirely suspended. In 
some instances the disease commences and proceeds with such violence 
as to exhaust the vital powers and terminate in death in the course 
of a single day. More commonly, however, the vomiting and purging 
are not so rapid as to prostrate the system immediately, and the dis- 
ease continues for five or six days before convalescence begins or fatal 
exhaustion ensues. In many instances the vomiting, in the course of 
four or five hours, becomes less and less frequent, and finally ceases 
altogether, or recurs two or three times daily, while the diarrhoea goes 
on until at last it assumes a strictly chronic character. In the early 
stages of the disease the little patient is evidently harassed with pain- 
ful and distressing sensations in the stomach and bowels ; and when 
the discharges are violent and very frequent, the muscles of the abdo- 
men and even those of the extremities are apt to become affected with 
spasmodic contractions. If the disease do not terminate fatally during 
the first few days, rapid emaciation ensues, the hands and feet become 
cold and pale, while the head and body are always preternaturally 
warm ; the skin is usually dry and harsh, and acquires a peculiar welted 
appearance, particularly on the inner part of the thighs and over the 
abdomen. The countenance becomes pale and contracted, the eyes in- 
animate and sunk, the nose sharp, and the lips thin, dry, and wrinkled. 

" The thirst is always very great, more especially after the disease 
has continued for some days, and no drink is palatable but cold water, 
which is generally thrown up soon after it is swallowed. Food of every 
kind is usually loathed and refused. If the disease be not subdued or 
moderated by proper remedial means, the little patient by degrees be- 
comes somnolent ; he sleeps with the eyes half open, rolls his head 
about when awake, and at last sinks into a state of insensibility and 
coma, and dies in a paroxysm of convulsions, or under symptoms re- 
sembling those of acute hydrocephalus. When the disease is of pro- 
tracted duration, or assumes a chronic form, the alvine discharges 
generally acquire a dark, very offensive, and acrid character. The 
digestive powers become so enfeebled that almost everything taken into 
the stomach passes through the bowels in an imperfectly digested state. 
Aphthae finally appear on the tongue and inside of the cheeks ; the face 
acquires a bloated or osdematous appearance ; the abdomen becomes 



508 CHOLERA INFANTUM. 

tumid and tympanitic ; the parts about the anus are excoriated by 
the acrid discharges, and towards the fatal conclusion spots of effused 
blood under the cuticle sometimes appear on various parts of the body, 
more especially on those upon which the patient lies. The little patient 
at last lies in a comatose and insensible state, with the eyelids half open, 
and the eye turned up so as completely to hide the cornea." 1 

This admirable description of Dr. Eberle at once points out the simi- 
larity and also the dissimilarity between the symptoms and course of 
cholera in infants and in adults ; but there are one or two other symp- 
toms, pointed out by Dewees, which are worthy of notice. One of them 
is a "crystalline eruption upon the chest, of an immensity of watery 
vesicles, of a very minute size. The best idea we can convey of the ap- 
pearance of this eruption is to imagine a vast collection of vesicles ap- 
parently produced by flirting an equal number of very minute drops or 
particles of boiling water, and each particle producing its vesicle." 2 Dr. 
Physick, Dr. Rush, and Dr. Condie, have witnessed examples of this 
eruption, but it appears to have escaped Dr. Eberle. 

Dewees considers it an invariably fatal symptom, but Dr. Condie says 
that he has " in many instances known the patient to recover, even 
w T hen this eruption has been the most extensive and distinct." It may, 
however, "readily escape observation, if not looked for; it requires that 
the surface in which it has spread itself should be placed between the 
eye and the light, and viewed nearly horizontally." " There is another 
symptom," Dr. Dewees adds, "which attends the last stage of this com- 
plaint, which is much more common but not less fatal, which is, the 
thrusting of the fingers, nay, almost the hand, into the back part of the 
mouth, as if desirous of removing something from the throat. The 
popular opinion is, that there is a worm irritating the back part "of the 
fauces. And we may mention another which we do not remember to 
have seen noticed, which is, the escape of a live worm or worms in the 
chronic stage of this affection. If the worm come away dead, there is 
nothing in the circumstance; but if alive, it is a fatal sign." 2 

735. The duration of this disease varies very much, sometimes ter- 
minating fatally in five or six hours, in other cases running on for many 
weeks. Children sometimes recover from the most hopeless condition, 
and in all such cases bilious matter reappears in the stools ; and always 
when this occurs, together with warm moisture of the skin, and a better 
pulse, we may hope for a favorable issue. But when the pulse is weak 
and thready, and the evacuations watery and colorless, or reddish and 
mixed with flocculi of mucus, with uneasiness and restlessness, or stupor 
and insensibility, we may fear the worst. 

1 Eberle on Diseases of Children, p. 283. I may just observe upon this last symptom, 
which, with the half-open eyelid, gives such a distressing look to the child ; that any one 
who has watched a baby go to sleep, or even carefully traced their own physical sensa- 
tions during the initiatory part of this process, must have observed that the turning up 
of the eyeball is almost invariable ; that in fact, it is one of the natural and healthy phe- 
nomena of sleep. 

2 Diseases of Children, p. 417. 



ENTERITIS. 509 



ENTERITIS. 

736. At the commencement of a bowel complaint, it is by no means 
easy to decide -whether it be an ordinary case of diarrhoea, or whether 
there may not be inflammation of the mucous membrane of the intestine, 
as the symptoms are much alike. Even at a later period, the distinction 
is not very marked; nor is the difficuly lessened by the fact, that when 
the diarrhoea has continued for some time as a functional disturbance, it 
is very liable to degenerate into enteritis or entero-colitis. 

Enteritis may commence, then, with moderate diarrhoea, which does 
not interfere with the child's comfort or its amusement for six or seven 
days, at which time there supervenes pain in the belly, fever, thirst, 
loss of appetite, and increase of the diarrhoea. 

Or the attack may be more sudden, with headache, vomiting, diarrhoea, 
pain in the bowels, fever, thirst, and loss of appetite. Or as I have 
seen in young infants, and verified by post-mortem examination, it may 
present at first neither pain, vomiting, purging, nor tenderness, but 
merely profound collapse. Other symptoms, as pain, diarrhoea, may 
subsequently be developed, but it is important to bear in mind that in- 
fants may die of enteritis with but little pain, and with no vomiting, 
purging, or tenderness, but in them the vital collapse is most marked. 

The ordinary symptoms then are vomiting, diarrhoea, heat, and tension 
of the abdomen from flatulence, and tenderness on pressure. The amount 
often varies; it is seldom very intense with young children. The tongue 
is found generally moist, red at the end, and along the edges; there is 
a disagreeable taste in the mouth, and the breath is offensive. The 
thirst is great, and the appetite lost. The vomiting continues for some 
days, and then subsides. The diarrhoea generally continues throughout 
the complaint, but in some cases it ceases as the disease advances. The 
abdomen is distended, and is painful when pressed ; rarely at the epi- 
gastrium, according to Rilliet and Barthez, but rather in the umbilical 
region or iliac fossae. The temperature of the abdomen is increased in 
proportion to the intensity of the inflammation, and is greatest when 
the disease is at its height. 

The color, consistence, and odor of the discharges vary much, nor 
do I believe that any very important inferences are deducible therefrom. 
They are sometimes green, sometimes yellow or reddish, brown, or clay- 
colored. Rilliet and Barthez give the following as the constituents 
of the stools, the varying proportions of which will influence the 
consistence and color : 1. The residue of the food, incompletely di- 
gested. 2. A secretion of serosity, which is not always present. 3. 
Mucus, which is almost always present, enveloping the more solid por- 
tions ; it is variously colored by the bile, is soft and gelatinous. 4. Bile, 
which colors the stools, and, alone or mixed with mucus, forms the 
clear or green flocculi. 5. Pus, the presence of which it is difficult to 
ascertain, unless the fecal matter be somewhat solid, upon which it then 
appears as streaks or lines. 6. False membranes, or their debris, are 
occasionally detected. 7. Blood, not fluid, nor occurring as hemorrhage, 



510 ENTERITIS. 

but mixed with fecal matter, in strise, brownish or bright red, or sanious, 
from mixture with mucus or pus. 1 

M. Billard mentions, that in four cases he found an exhalation of 
blood from the mucous membrane in erythematous enteritis. 2 

The evacuations are almost always voluntary, and passed consciously, 
except towards the termination of the disease ; but in some cases the 
urgency is so sudden and so great that the child has not time to call 
for assistance, and has, therefore, erroneously been supposed to have 
involuntary motions. 

As the disease advances, the skin becomes dry, pale, yellowish ; the 
face wrinkled, old-looking, and expressive of depression and distress ; 
the debility and the emaciation are very great. M. Jadelot lays great 
stress upon the lineaments of the face. " One of the most certain marks 
of abdominal affection is the first general lineament, which extends from 
the commissure of the lips to the lower part of the face, where it loses 
itself; the second, the nasal lineament, extends from the inside of the 
alae of the nose, and surrounds the whole of the orbicularis oris muscle. 
These are not to be always seen in very young infants, yet some trace 
of them may be observed, as a fold, on the commissure of the lips, or 
outside of the orbicular muscle, corresponding with the nasal lineament. 
When the child suffers violent pain, there is a corrugation of the skin 
of the forehead; and indeed the sudden appearance of wrinkles in any 
part of the face almost always indicates the presence of abdominal pain, 
and demands the attention of the physician, for they are invariably 
marks of distress not to be overlooked. A pinched expression of face, 
without the presence of any particular lineament, in very young infants, 
is always a sign of gastro-intestinal inflammation." 3 

737. Chronic Diarrhoea. — Functional disturbance of the bowels, if 
not fatal, may subside into a chronic form of diarrhoea; acute enteritis 
may also be succeeded by the chronic phase of the disease, and the 
similarity between these chronic disorders is even greater than between 
the acute forms. The bowels continue relaxed, with a considerable 
variation in the character, quantity, color, and consistence of the dis- 
charges, occasional griping pain, tympanitic inflammation of the abdo- 
men, great general emaciation, loss of appetite, thirst, foul tongue, &c. 
The fever assumes a kind of remittent type, but is never very intense; 
the pulse is rather quicker than natural, but weak. The surface is dry, 
and becomes of a dirty color. 

Dr. Dewees has included "weaning brash" in his description of 
chronic diarrhoea, and in some instances it may fairly be so denomi- 
nated, but it is generally more acute, and the irritation involves the 
stomach as well as the intestinal canal. 

738. Let us now briefly notice the complications of this intestinal 
disorder, or those secondary affections which are most apt to occur in 
its course. 

I. We found, when treating of muguet, aphthge, ulceration of the 
gums, cancrum oris, pseudo-membranous pharyngitis, &c, that in a great 

1 Mai. des Enfans, vol. i. p. 494. 2 Mai. des Enfans Nouveaux-nes, &c.,p. 202. 

3 M. de Salle's translation of Underwood. Stewart on Dis. of Children, p. 253. 



DIARRHCEA. 511 

proportion of cases they were secondary to an inflammatory affection of 
the intestinal canal ; and every day's experience shows us that at least 
the milder forms may occur in the course of acute or chronic diarrhoea, 
where no decided evidences of actual inflammation are present. 

ir. Children suffering from any of the varieties of diarrhoea, from 
cholera infantum, or from enteritis, are very liable to affections of the 
nervous system, and this either at the commencement, or after the pri- 
mary disorder has continued some time. Tn the first, we find the 
diarrhoea set in furiously with high fever, heat of skin, quick pulse, &c, 
and then a convulsion partial or general. In the latter case, and by 
far the more frequent, the convulsion is generally preceded by sleepi- 
ness, starting, wildness of eye, stupor, or coma ; the cerebral irritation 
advances more slowly, but is even more to be feared. A post-mortem 
examination does not necessarily afford evidences of meningitis, but yet 
the complication requires a modification of similar treatment, and will 
prove equally fatal if the remedies be not early and skilfully applied. 

in. Dr. Stewart states that there are many marks of irritation in the 
pulmonary system ; but my experience would rather confirm the obser- 
vations of Rilliet and Barthez, that this is a comparatively rare compli- 
cation. No doubt a child suffering from diarrhoea will occasionally 
have a short cough, but I do not think that we often see bronchitis well 
marked in such cases. 

739. Morbid Anatomy. — I. So long as the diarrhoea is not inflam- 
matory, a ]Jost-?nortem examination will reveal but few changes beyond 
the presence of the peculiar secretion in the intestines. 

Out of twenty-eight cases, M. Legendre observed four in which there 
was not the slightest change in the mucous membrane, although the 
disease had lasted from three weeks to four months. He considers that 
the morbid conditions which are found are the consequence of the pro- 
longed secretion. 1 

M. Billard has discovered enlarged muciparous follicles, but not 
inflamed, in children dying from excessive serous discharges ; and this 
I believe is nearly all the positive alteration observed, unless the disease 
run on into inflammation. Most of the morbid appearances recorded 
as having been noticed in cases of diarrhoea, were the result of inflam- 
mation, and prove the cases not to have been mere irritation, or to have 
transcended those limits. We shall presently enumerate them. 

Dr. West has quoted in a note the experience of Messrs. Friedleben 
and Fleisch, from the Zeitschrift fiir Rationelle Medicin, vol. v. 1846. 
" Their observations are founded on fifteen infants, all of whom were 
under one year old, who were brought up either exclusively, or in a 
great measure, on artificial food, and who died, after long-continued 
illness, in a state of atrophy ; or else sank rapidly under profuse watery 
diarrhoea. In cases of the former class — a state regarded by the 
writers as the result of chronic inflammation of Peyer's glands — were 
the chief morbid appearances ; while in those instances where death 
took place rapidly, a swollen and congested condition of the same bodies, 
betokening, as they believe, their recent inflammation, was almost 

1 Recherches, &c. sur quelquesMal. de l'Enfance, p. 867. 



512 CHOLERA INFANTUM. 

always present. They found, too, that in all these cases the disease of 
the colon was comparatively slight, and was evidently secondary to the 
more serious changes in the small intestine." 1 

M. Legendre alone, I believe, has noticed the fatty degeneration of 
the liver in prolonged diarrhoea. The organ is not increased in size, 
nor is its specific gravity diminished, but its color is mottled with yel- 
low patches. 2 

II. In cases of cholera infantum., the liver is almost always engorged, 
and generally greatly enlarged. Dr. Dewees speaks of its occupying 
two-fifths, 3 Dr. Lindley 4 one-half, and Dr. Horner 5 two-thirds of the 
abdominal cavity. It is firmer and more solid than natural, but with- 
out perceptible change of structure. There are abundant evidences of 
inflammation in the stomach and small intestines ; red, inflamed patches, 
inclining to purple, may be observed, especially in the duodenum ; nor 
are they limited to the small intestines, as Drs. Jackson and Dewees 
thought, Dr. Horner and others having found them in the large intes- 
tines. Dr. Horner has added another pathological characteristic to 
those observed before ; he has shown that very extensive inflammation 
of the mucous follicles of all the intestines is present, in this agreeing 
with the observations of MM. Billarcl, Roederer and Wagler. 

III. The morbid changes discovered in the mucous membrane of the 
small intestines in enteritis are very similar to those we noticed in the 
stomach. Redness, partial or general, occasionally limited to a small 
portion of the intestine, with or without ramollissement. This erythe- 
matous inflammation is the most common ; pseudo-membranous enteritis 
is more rare, and is seated at the lower portion of the intestine. Sim- 
ple ulceration is comparatively rare ; most commonly the ulceration is 
follicular. But here again we meet with inflammation of the follicles 
and of the groups of glands. The isolated follicles are prominent, 
rounded, and giving to the finger the sensation of a grain, somewhat 
soft, about the size of a pin's head ordinarily, and occasionally some- 
what larger. They are more voluminous in the upper than the lower 
portion. Paler and more transparent than the rest of the mucous 
membrane, they are sometimes surrounded by a red circle. When 
punctured, there escapes a drop of serous fluid. 

The glands of Peyer are frequently inflamed, and become swollen 
and thickened, and are easily removed by scraping with the scalpel. 
Their surface may have a mammelonated appearance, or be equally 
developed and prominent ; red, or of a rose color ; smooth, with a 
number of depressed points, the orifices of the mucous follicles. 6 

Dr. West thus sums up the alterations he has observed in the small 
intestines: "They consist in a more or less intense redness of the 
mucous membrane, which appears thickened, and presents something of 
a velvety appearance, shaded over with numerous dark spots, the ori- 

1 Diseases of Infancy and Childhood, p. 895, note. 

2 Recberches sur quelques Mai. de l'Enfance, p. 376. 

3 Diseases of Children, p. 400. 

4 American Journal of Medical Science, vol. xxiv. p. 305. 

5 Ibid, for February, 1829. 

6 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 478. 



ENTERITIS. 513 

fices of the solitary glands. In other instances, the surface of the 
reddened mucous membrane appears slightly roughened, as if sprinkled 
over with fine sand ; while near to the caecum the roughening is often 
greater, the membrane appearing elevated into rough, orange-colored 
prominences, separated by narrow lines, of a dead white color, which 
mark the situations where, by the destruction of the mucous membrane, 
the subjacent tissue is exposed." " Besides this affection of the mucous 
membrane of the ilium, Peyer's glands are not unfrequently very well 
marked in the lower part of the small intestine ; and their surface 
presents a punctated appearance, due to the unusual distinctness of 
the orifices of the sacculi which compose each gland. Occasionally a 
few of them are congested and swollen, and once or twice I have ob- 
served one or two spots of ulceration on that cluster of Peyer's glands 
which is situated close to the ileo-csecal valve ; but in every instance the 
affection of the small intestine has appeared to be secondary and quite 
subsidiary to the disease in the colon." 1 

The mesenteric glands are most frequently unaffected ; sometimes 
they have been observed to be increased in size and congested, but in 
general they retain their normal appearance and size. 

Softening of the mucous membrane is extremely common in infants, 
either limited in extent or extending throughout the intestine. 

740. In some rare cases, traces of cerebral congestion, or of disease 
of the membranes of the brain are discoverable, but in general, even 
when head symptoms have occurred, but little information is obtained 
by a post-mortem examination. 

The lungs are almost invariably healthy, and the mucous membrane 
free from inflammation, quite justifying the remark I made as to the 
rarity of such complication with diarrhoea. 

741. Causes. — All the varieties of irritation and inflammation of the 
intestinal canal are as common with infants as with older children. I 
do not think we can say more common, although the delicate unused 
condition of the mucous membrane might well predispose them to it. 2 

The chief causes of diarrhoea are, cold, damp, improper food, or 
excess of proper food, dentition, and variations of atmospheric tem- 
perature. 

On a comparison of the results of five years' observation at the 
Children's Infirmary, Dr. West found that 

In the three months, 

Nov. Dec. and Jan. diarrhoea formed 7.2 per cent, of all cases of disease. 

Feb. March, and April, 8.3 " 

May, June, and July, . . 18.0 " " 

August, Sept. and Oct. . . 24.4 " " 

Dr. Condie very truly remarks that food, which is ordinarily suit- 
able, will sometimes disagree with the same children, and give rise to 
diarrhoea ; and during infancy, of course, the babe will be affected by 
any change in the nurse's milk, whether the result of bodily or mental 
conditions. 

1 Diseases of Infancy and Childhood, p. 394. 

2 West, Diseases of Infancy and Childhood, p. 388. 

33 



514 ENTERITIS. 

The loose discharges about the period of dentition appear connected 
with the enlargement and inflammation of the mucous follicles, as 
Billard has observed ; and M. Bouchut found that only twenty-six 
out of 110 actually escaped at this age, whilst forty-six suffered very 
severely. 1 

Mucous diarrhoea occasionally follows the suppression of cutaneous 
eruptions, or the drying up of sore ears. 

742. Qholera infantum seems limited by age, few cases occurring 
beyond the second, and never beyond the fifth year. " During twenty 
years, the deaths from cholera infantum in Philadelphia amounted to 
8576 ; namely, in infants under one year of age, 2122 ; between one 
and two years, 1186 ; between two and five years of age, 268." "The 
influence of a high atmospheric temperature in the production of cholera 
infantum is shown by the fact that its prevalence is always in proportion 
to the heat of the summer, increasing and becoming more fatal with the 
rise of the thermometer, and declining with the first appearance of cool 
weather in the autumn. A few hot days in succession in the month of 
May are sufficient to produce it ; while in the height of its prevalence, a 
short period of cool weather will diminish, if not entirely suppress it." 2 

But heat alone is not sufficient ; it requires in addition confined and 
impure air, for we find that the disease is nearly confined to large 
cities — that little or none is seen in the country, although the heat is 
quite as intense. Infants who have been prematurely weaned, and 
children whose diet is bad or in excess, are extremely obnoxious to an 
attack, and probably the irritation of dentition may be among the pre- 
disposing causes. 

The causes of enteritis are almost identical with those of diarrhoea. 
Unwholesome food, irritating matters, excess, dentition, cold, impure 
air, &c, are as likely to give rise to the severer as to the milder affec- 
tion. 

743. But we must not forget that diarrhoea, whether functional or 
organic, may in any or all of its varieties be a secondary affection, and 
that this may either be the result of the primary disease, or of the 
remedies employed in its cure. 

Thus we find that in the course of the eruptive fevers, meningitis, 
bronchitis, pneumonia, &c, diarrhoea is very apt to set in, and espe- 
cially when these have been treated by calomel, tartar emetic, or pur- 
gatives. 

The symptoms do not differ materially from those already enume- 
rated, although they are more or less masked by the predominance of 
the primary disorder. We find diarrhoea, pain, and perhaps some de- 
gree of tenderness, tympanitic swelling, and tension of the abdomen ; 
which may subside, all but the diarrhoea ; the tongue is moist, red at 
the point and edges, the face becomes pale and wrinkled, with the naso- 
labial trait well marked, the eyes are hollow, &c. ; and this condition 
may continue until either the primary disease is cured or proves fatal. 

Or the attack may come on more suddenly and more severely in the 
course of an acute disease, with excessive vomiting, copious diarrhoea, 

1 Mai. cles Nouveaux-nes, p. 196. 2 Condie cm Diseases of Children, p. 215. 



ENTERITIS. 515 

tension and enlargement of the abdomen, with a disproportionate de- 
gree of tenderness (so as almost to lead us to suspect peritonitis), great 
exhaustion, &c. 

744. Diagnosis. — I. The distinction between diarrhoea from exces- 
sive secretion, and that which is the result of enteritis, is by no means 
easy, not only from the similarity of symptoms and course, but also 
because the former is very apt to run on into the latter. The most 
characteristic difference is the amount of fever, the pain, and the ten- 
derness on pressure, which are much more marked in the latter. 

II. On the other hand there is less acute tenderness, less pain and 
fever, in enteritis than in peritonitis ; the expression of countenance is 
different also. 

in. The previous history will almost always show that the head 
symptoms are secondary, and that, therefore, we are not called upon 
to treat simple meningitis. The previous, and in most cases the pro- 
longed diarrhoea, and the gradual development of nervous symptoms, 
are very unlike the course of the disease when primary. 

745. Prognosis. — I. In simple diarrhoea, if we see the case early, 
our prognosis will upon the whole be favorable ; but if the disease be 
of longer standing, and have resisted the ordinary means of relief, we 
cannot conceal from ourselves that considerable danger attends the 
complaint. A cessation of vomiting, a decrease of the purging, sub- 
sidence of the abdomen, and the return of appetite, constitute the 
favorable symptoms, while an increase of these symptoms with higher 
fever, or sinking, or the accession of any complication, especially of the 
head, will leave but little hope. It is scarcely possible to have a more 
fatal complication than a cerebral attack towards the termination of an 
exhausting diarrhoea. 

II. The same observations will apply to moderate cases of enteritis. 
In severe cases, the prognosis is more unfavorable, and the chances of 
some fatal complication greater. 

in. Cholera infantum is a most fatal disease; a very large proportion 
of children are carried off by it. 

746. Treatment. — The first duty is to remove every possible cause 
of the disease. If we have any reason to suppose that the nurse's milk 
does not agree with the child, it will be necessary to change the nurse; 
and it will be well to choose one whose child is rather older than our 
patient, as the younger the milk the more likely it is to purge the 
infant. 

If the child be weaned, we must correct any errors of diet, either as 
to quantity or quality, and, as a general rule, substitute a bland, milky, 
or farinaceous diet for any kind of animal food. Ass's milk for young 
children, arrowroot, tapioca, panada, &c, are all very wholesome in 
irritations of the intestinal canal. 

If the teeth be at all at or near the surface, or even when at some 
distance, if the child suffer from irritation of the gums, they ought to 
be freely divided down to the teeth, and rather beyond the limits of 
those coming to the surface. Very often the irritation which a child 
would bear in health without any inconvenience will be quite sufficient 
to neutralize the effect of our remedies when diarrhoea is present. 



516 ENTERITIS. 

747. These points being attended to, we have next to consider what 
medicines we shall employ, and, on the supposition that irritating mat- 
ters require to be removed, many physicians commence with a purgative 
of rhubarb, magnesia, or castor oil. Undoubtedly, if such matters were 
in the intestinal canal, this would be right, but disordered evacuations 
are no proof of it ; and I very much prefer calming the irritation first, 
and then, if necessary, clearing out the bowels. 

For this purpose, nothing is better than the chalk mixture with some 
aromatic and a drop or two of laudanum to the ounce. I find that 
small divided doses answer just as well as larger ones ; and I prefer 
laudanum to syrup of poppies, because, if fermentation take place with 
the latter, the acetate of morphia is formed, and the child may get an 
overdose. 

Mucilage, syrup, sal volatile, aniseed water, with the same amount of 
laudanum, will answer equally well, with the advantage of being slightly 
stimulant. Or the hyd. c. creta may be combined with the pulv. cretse 
c. opio, or with Dover's powder, in proportions according to the age of 
the child. 

A starch enema, containing a few drops of laudanum, will often 
relieve the irritation quicker than anything else, and, given at bedtime, 
will secure a good night's rest. It may be repeated as often as ne- 
cessary. 

If the discharges be acid, we may combine an alkali with the fore- 
going. 

I have found great advantages in obstinate cases from the use of ex- 
ternal irritation, either by mustard and meal poultices, or the compound 
camphor liniment with laudanum. A plain poultice applied twice a day 
affords great comfort, or the abdomen may be fomented. 

If the discharges continue and are still excessive, a more decided 
astringent may be given ; the infusion of catechu, or decoction of log- 
wood, or the tincture of kino; or catechu may be added to the chalk 
mixture. 

Dr. West speaks most highly of the extract of logwood and tincture 
of catechu, five grains of the former and ten minims of the latter, to be 
given three times a day, in some sweetened aromatic water, to an infant 
a year old. 

" Pure argil has been of late much used in diarrhoea accompanied 
with acidity, as it forms with the acids an astringent salt. The substance 
is prepared from the sulphate of ammonia and alumina, by exposing it 
to a strong red heat in a crucible. Argil in the form of a white powder 
possesses great astringent powers. Riecke recommends the formulas 
which are subjoined." 1 

R. — Emuls. sem. papav. ^iijss. 
Argillse puras, J}ij. 
Syr. althsese, ijss. — M. 
A teaspoonful for a child two years old. 



1 Stewart on Diseases of Children, p. 198. 



ENTERITIS. 517 

R. — Argill. pune ^ss. 
Gum. Arab. gj. 
Sacch. alb. gij. 
Aquas fceniculi, giij. — M. 
A teaspoonful for a child a year old. 

748. The foregoing treatment seems so far suitable to any of the va- 
rieties of diarrhoea ; but some modifications have been suggested in the 
different species. In mucous diarrhoea, we are advised to endeavor to 
restore the action of the skin as well as to restrain the discharge, and 
for this purpose ipecacuanha has been recommended by Good, Dewees, 
Stewart, Condie, &c. 

Dr. Good gives it alone or united with opium, Dr. Stewart alone or 
with cretaceous preparations, and Dr. Condie combines it with calomel, 
acetate of lead, and hyoscyamus. As an astringent, Dr. Stewart speaks 
highly of an infusion of the root of the geranium maculatum, half an 
ounce to a pint, and also an infusion of the bark of the rubus villosus, 
or common blackberry. To an infant of six months, a teaspoonful may 
be given five or six times a day, and a tablespoonful to a child of two or 
three years. Dr. Eberle recommends a few drops of the balsam copaiba 
in emulsion when mucous diarrhoea is somewhat chronic; and Dr. Con- 
die has found it very useful. 

In bilious diarrhoea we are advised first to clean out the bowels, and 
then to give small doses of calomel with laudanum, or the hyd. c. creta 
with Dover's powder. Dewees recommends the tartrate of antimony 
in small doses, but I confess I should be very unwilling to give it, lest 
it should increase the gastric irritation, or perhaps give rise to gastritis. 

M. Trousseau recommends the neutral salts, ipecacuanha, and, if 
there be much mucous disturbance, opium. 1 

The child should be removed to a cool atmosphere, have a tepid or 
warm bath daily, and drink plentifully of gum water, rice water, &c, 
aud be supported by a bland farinaceous diet. 

In chylous diarrhoea Dr. Dewees advises low diet, rennet whey, or 
gum water, anodyne injections at night, and minute doses of calomel 
during the day — "say a quarter grain every four hours, with the twen- 
tieth of a grain of opium." "We have thought we derived advantage 
from the application of a blister to the back of the neck, and keeping 
the body unusually warm." 2 

Very much the same kind of treatment is recommended for Uenteric 
diarrhoea ; abstinence from much food, and that given to be milky or 
farinaceous; frictions to the abdomen, chalybeate water, with a minute 
dose of laudanum, fresh pure air, &c. Dr. Dewees ordered friction with 
tartar emetic ointment; but for reasons before stated, I very much prefer 
compound camphor liniment, or a mustard and meal poultice, or a blister. 

M. Trousseau states that the stools are acid, and to correct this he 
gives either magnesia, from one to five grains daily ; lime-water, one 
scruple to one drachm; or the bicarbonate of soda from two to eight 
grains. In addition he advises mineral baths, containing from two to 
six ounces of sulphate of iron, sulphurous or aromatic baths, with decoc- 

1 Banking's Abstract, vol. iv. p. 202. ' Diseases of Children, p. 891. 



518 ENTERITIS. 

tions of sage, lavender, or rosemary, a pint of red wine, and common 
salt; fresh air and sunshine. 

749. In cholera infantum the great desideratum is to tranquillize the 
stomach ; until that is done not only is the disease unchecked, but the 
suitable remedies cannot be exhibited. For this purpose Dewees recom- 
mends warm water to "encourage the puking," and enemata of warm 
water to clear the bowels. This appears to me to be acting upon the 
supposition that there is some irritating matter still in the stomach and 
bowels; and, with all respect to Dr. Dewees and others who have advo- 
cated the same plan, I believe it to be an error, or at all events an assump- 
tion of which we have no proofs. That discharges are foul and acrid 
does not prove that they cause the evacuations ; it only proves that 
such discharges have their origin in disordered action or secretion, and 
it is to that our attention should be directed. 

Calomel in small doses rubbed up with sugar ; or the hyd. c. cretti 
with Dover's powder, or small quantities of laudanum in a mixture, 
may be given with very good effects. Anodyne injections, warm baths, 
warm and stimulating frictions to the extremities, with stimulants 
internally, if there be much threatening of collapse, must all be tried. 
A blister over the stomach will often arrest the vomiting. " When 
the vomiting persists, we have found a few drops of spirits of turpentine, 
or of a solution of camphor in sulphuric ether, repeated at short inter- 
vals, seldom fail in removing it. When the vomiting is violent and 
frequent the application of a few leeches to the epigastrium "will be 
found decidedly advantageous. When everything else fails we have 
very seldom been disappointed in removing irritability of the stomach 
by the administration of the acetate of lead in solution." 

Dr. Eberle recommends the plan first adopted by Dr. Parrish, of 
blistering behind the ears in cholera, and the administration of small 
doses of calomel and ipecacuanha, and a stimulating poultice over the 
abdomen. 

If we suspect the existence of acid in the stomach and bowels we 
may combine chalk with the calomel, or we may adopt Dr. Kuhn's 
plan of giving magnesia with ammonia. Dr. Condie gives Kuhn's 
formula as follows : 

R. — Magn. calcin. "&'iv. 
Pulv. g. Arab. Qj. 
Sacch. alb. gij. 
Aq. menth. pip. §ss. 
Aquas font. §ijss. 

Aquas ammoa. pur. gtt. xlviij. to gtt. clxiv., according to the age of 
the child. 
The dose is a teaspoonful every two hours. 

When the stomach is quieted we may have recourse to any of the 
remedies already mentioned, to restrain the action of the bowels ; of 
these, probably, the acetate of lead and opium, in small doses, propor- 
tionate to the age of the child, will be found the best ; and when these 
watery discharges are diminished or changed for those containing 



ENTERITIS. 519 

feculent or bilious matters, the treatment will then be the same as for 
diarrhoea. 

When cholera infantum becomes more chronic we may have recourse 
to warm baths, frictions or blisters to the abdomen, anodyne injections, 
astringents, and a slight improvement in the diet. Some of the prepa- 
rations of iron may be tried. Eberle speaks highly of the tartrate, 
others of the persesquinitrate of iron. Sulphate of quinine is also 
very useful occasionally. Dr. Condie recommends powdered charcoal 
in conjunction with rhubarb, ipecacuanha, and hyoscyamus, when the 
discharges are acrid, offensive, and dark colored. 

In addition, as the disease appears to be produced by hot, impure air, 
and deficient ventilation, the child ought to be removed to a cooler and 
purer atmosphere ; and, as soon as the stomach will bear it, the diet 
must be improved in quality, and stimulants given in due proportion to 
the age and circumstances of the child. 

750. The treatment of enteritis differs but little from that of gastritis 
detailed in the last chapter, except that, when it has been preceded by 
exhausting diarrhoea, we must be cautious not to push antiphlogistic 
remedies too far. 

If the pulse be pretty good, and the prostration not too great, we 
may apply leeches to the epigastrium, in number according to the age 
and strength of the infant, intensity of the disease, &c. ; and the bleed- 
ing should be stopped immediately, unless we superintend the operation 
ourselves, as Maunsell and Evanson suggest. It is easy to repeat the 
leeching, if necessary, but far from easy to remedy excessive loss of 
blood. 

Warm baths, when the child is not too weak, and fomentations to the 
abdomen, are most valuable ; or, what is less troublesome, a succession 
of nice, warm, soft poultices. I do not think the profession in these 
countries are fully aware of the great value of poultices in internal and 
deep-seated inflammations. Nothing can be more marked than the 
relief afforded, and their soothing effect upon children. 

Some degree of counter-irritation may also be necessary, either by 
means of mustard poultices, liniments, or blisters. Sinapisms or even 
blisters may be applied to the extremities with benefit. 

Internally calomel or gray powder will be very useful, if it can be 
given without increasing the irritation ; and if not, we may either use 
mercurial inunction, or dress the blister with mercurial ointment. 

Opium alone, or in combination with the above, or in the form of 
laudanum, pulv. cretse cum opio, or Dover's powder, will afford relief 
from the pain and gastric irritability, and will render tolerable other 
remedies. 

The diarrhoea may generally be arrested by some of the astringent 
remedies mentioned already — chalk, lead, kino, catechu, &c. ; and the 
diet must be carefully regulated. It is not a prime object to accumulate 
nourishment ; if this be given too soon the disease will rather be in- 
creased. Mucilaginous drinks, or milk, with very light, thin, farina- 
ceous food, appear to be the most suitable ; and when the disease is on 
the decline, then we may gradually give more nourishment, and wine if 



520 ENTERITIS. 

necessary. Of course every possible exciting cause must be removed, 
and the gums lanced, if required. 

751. Chronic diarrhoea requires a slight modification of the treat- 
ment already laid down. In addition to the calomel, chalk, ipecacuanha 
and hyoscyamus, recommended by Dr. Condie, the acetate of lead, with 
or without laudanum, the vegetable astringents, &c, we are advised to 
try spirits of turpentine, balsam copaiba, the persesquinitrate of iron, 
in doses of two or three drops of the liquor every two or three hours, in 
sugar and water, &c. 

One of the occasional symptoms I have already noticed, the prolapsus 
ani, demands a word as to its treatment. So far as it depends upon 
relaxation resulting from frequent discharges, the relief of the diarrhoea 
will cure it at the same time ; but it does often remain, because of the 
habit of sitting long at stool and forcing, which the child acquires 
during the course of the disease. Now, in order to remedy this effect- 
ually, all we have to do is to place a board, with a small perforation, 
across the chair or vessel the child uses, and to place the latter so that 
the child cannot touch the ground with its feet. So circumstanced, no 
excessive forcing can be used, and I have repeatedly found the plan 
successful. I am indebted for the suggestion to my friend Dr. Corrigan 
of this city. 

It will rarely, if ever, be necessary to have recourse to any surgical 
operation for its cure. If it persist, a little gall ointment, or a small 
astringent injection occasionally, will almost always be sufficient. I 
need hardly say that the gut is to be returned immediately each time 
it prolapses, by applying gentle pressure with one or two fingers, pre- 
viously oiled. 

Another very troublesome occurrence, as Dr. West has remarked, 
is the intertrigo occasioned by the contact of acrid fasces. Generally 
this results from want of due cleanliness, but I have seen it in children 
with an irritable skin in spite of the utmost care and watchfulness. The 
best remedy is careful sponging after each evacuation, and anointing 
the parts, when dried, with zinc ointment, zinc cream, or ointment of the 
acetate of lead. Dusting the neighboring parts with lapis calaminaris 
is also of great use in protecting them. 

752. As regards the complications I need not say much, having 
already treated very fully of them; and I must refer the reader to the 
chapter on diseases of the mouth and pharynx. Bat I wish to impress 
most forcibly upon all, the importance of carefully watching for the 
first inroads of cerebral complications, and of promptly applying the 
very few suitable remedies at our command. It is not often that we 
can venture to apply leeches under these circumstances ; if the case will 
admit of it of course it should be done ; but if not, we must have re- 
course to counter-irritation to the scalp or to the extremities, and to 
calomel, if the stomach and bowels will bear it, or to mercurial inunc- 
tion or dressings. 

Notwithstanding the head symptoms, we are not to abstain from 
opiates, if the state of the bowels requires it, because the continuance 
of that irritation will be far more injurious to the brain than the small 
quantities of laudanum I have recommended. 



DYSENTERY. 521 

Again, the head symptoms show themselves very often at the time 
when the constitution of the child has been so much weakened as to re- 
quire wine or other stimulants ; and although these are somewhat 
counter-indicated by the attack of the nervous system, I have found the 
child suffer more by their omission than by their continuance. I re- 
commend, therefore, that they should be continued, but with caution 
and watchfulness. 

753. Secondary diarrhoea, with or without enteritis, requires no other 
modification of the treatment here specified than what results from the 
coincident treatment of the primary malady, and the state of constitu- 
tion induced by it. 

The diet I have mentioned should in every variety be bland, milky, 
and farinaceous ; very moderate also fti quantity, and repeated at dis- 
tant intervals, so as not to give the stomach too much to do at once. 
Fresh, pure air, and a change from town to the country, is of great 
value. Warm baths, to cleanse the skin, and promote its functions, 
absolute cleanliness, and suitable warm clothing, are quite necessary. 
I have seen most beneficial effects in chronic diarrhoea from a swathe of 
new flannel being worn round the abdomen next to the skin. 



CHAPTER XVII. 

DYSENTERY. — COLITIS. 

754. In the last chapter I mentioned that inflammation of the small 
intestines was frequently accompanied by inflammation of the large 
intestines, constituting the entero-colitis of the French authors; nay 
more, that this compound affection was of more frequent occurrence 
than either element separately ; and some evidence of the morbid lesions 
was brought forward under the head of morbid anatomy. Rilliet and 
Barthez have given a table of these diseases, and of their conjunction 
numerically, and I shall quote it, in the hope of impressing upon my 
junior readers the difference between a written description of disease 
and clinical experience; how what is very clear and definite in the one 
is obscured by combinations and modifications in the other, which yet 
cannot be described on paper ; and how necessary it is in practice to 
bear in mind the relations of one disease to another, as well as the 
characters of each disease. 

The authors I have named met with forty-five cases of enteritis, and 
113 cases of colitis, either erythematous, pseudo-membranous, ulcerous, 
or pustulous; ninety cases of follicular enteritis; sixty-four cases of 
follicular colitis; twenty-eight cases of softening of the small intestines ; 
and thirty-five cases of softening of the large intestines ; and these, 
occurring in 185 cases, were thus associated : 



522 



DYSENTERY. 



Enteritis alone, in 2 cases. 

Colitis alone ........... 32 " 

Entero-colitis alone 11 " 

Follicular enteritis alone 12 " 

Follicular colitis alone 3 " 

Follicular entero-colitis alone 10 " 

Enteritis and follicular enteritis 8 " 

Colitis and follicular colitis 12 " 

Enteritis and follicular entero-colitis 2 " 

Colitis and follicular enteritis ........ 17 " 

Colitis and follicular entero-colitis . . . . . . . 11 " 

Entero-colitis and follicular enteritis ...... 7 " 

Entero-colitis and follicular colitis 4 " 

Entero-colitis and follicular entero-colitis . . . . 7 . " 

Softening of the large intestines ....... 8 " 

Softening of the small and large intestines . . . . 10 " 

Enteritis and softening of the large intestines 1 case. 

Colitis and softening of the small intestines 2 cases. 

Colitis and softening of the large intestines ..... 1 case. 
Enteritis, colitis, and softening of the large intestines ... 2 cases. 
Softening of the small intestines and follicular enteritis ... 1 case. 
Softening of the large intestines and follicular colitis . . . 1 " 
Softening of the small intestines and follicular colitis . . 1 " 

Softening of the small intestines and follicular entero-colitis . . 1 " 
Softening of the large intestines and follicular enteritis ... 3 cases. 
Softening of the large intestines and follicular entero-colitis . . lease. 
Softening of the small and large intestines, and follicular enteritis . 2 cases. 
Softening of the small and large intestines, and follicular colitis . 2 " 
Softening of the small and large intestines, and follicular entero-colitis 3 " 
Colitis, softening of the small intestines, and follicular enteritis . 1 case. 
Colitis, softening of the small intestines, and follicular colitis . . 3 cases. 
Colitis, softening of the small intestines, and follicular entero-colitis 3 " 
Entero-colitis, softening of the large intestines, and follicular enteritis' 1 case. 

From this minute tabular view, it is evident that no arrangement or 
division of these affections can be based upon morbid anatomy; for we 
find in a great number of cases that lesions of the large and small 
intestines are more frequently conjoined than separate ; and that, there- 
fore, in making a distinction, we must rather be guided by the history 
and symptoms of the disease than by the result of post-mortem examina- 
tion. So far, however, this distinction is borne out, that we do, in fact, 
find, in a certain number of cases, that the disease of the small and large 
intestines existed separately, and that the latter cases were much more 
frequent than the former. 

755. Without any wish, therefore, to make a clearer distinction than 
we find at the bedside, I have still thought it well to treat the irritation 
and inflammation of the small intestines separately in the last chapter ; 
and to complete the history of this complicated affection of the digestive 
tube, by treating of colitis, or, as it is usually termed, dysentery, in the 
present chapter; first, repeating that, as in the former disorder, when 
disease of the small intestines predominated, we found that the large 
intestines participated, to a certain extent; so in the present disease of 
the large intestines, we shall find that the small intestines are by no 
means in a state of integrity. 

Dysentery, then, consists in an inflammation of the large intestines 
chiefly, and may occur in children of any age; although it appears to be 
less frequent in infants than older children. 

1 Mai. des Eufans, vol. i. p. 488. 



DYSENTERY. 523 

It may present itself in either an acute or chronic form, and may be 
either primary or secondary. 

756. I shall first notice Acute Primary Colitis. This may be 
developed in the course of ordinary entero-colitis by the diminution of 
the enteritis, and the consequent predominance of the inflammation of 
the large intestine, and the early symptoms will be those of which I 
spoke in the last chapter. 

Or it may commence by uneasiness, broken sleep, irritability, some 
increase of the regurgitation of milk, and diarrhoea of feculent matter. 
So far the attack appears one of simple diarrhoea, without fever, and 
with the mouth cool and moist. 

After a few days, however, the disease changes its character a good 
deal, the evacuations become more frequent, smaller, and with less fecu- 
lent matter, until they consist of little more than small quantities of 
mucus mixed with blood, or even of blood chiefly. They are preceded 
by pain and followed by tenesmus; indeed, it is difficult to induce the 
child to leave the chair, or to forbear extreme forcing. Occasionally 
masses of feculent matter are expelled. The abdomen swells, becomes 
hot, tympanitic, tense, and tender, and there is a corresponding degree 
of fever, with hot skin, quick pulse, and evening exacerbations. The 
child rapidly emaciates, his flesh feels flabby and soft, his face is dis- 
tressed and anxious, wrinkled, and with a look of age ; the eyes are 
dull, sunk, and with a dark circle around them. 

757. If the disease be not arrested these symptoms increase. The 
abdomen becomes more distended, and very tender on pressure ; the 
child complains of severe pain, especially when the bowels are moved ; 
the discharges may preserve their ordinary character, or they may 
become dark-colored, acrid, and highly offensive. 

From the irritating nature of the evacuations the anus and surrounding 
parts become red, hot, painful, and excoriated. M. Bouchut observes, 
that " erythema of the thighs and buttocks exists in five-sixths of the 
cases of entero-colitis. It commences with the disease, and appears 
ordinarily some days previously. At first there is simple redness, with 
reddish papulae, more or less confluent, on the thighs, scrotum, or vulva, 
and on the inside of the limbs down to the ankles. The epidermis on 
these papulae becomes eroded, and superficial ulcerations, whose red and 
bleeding surface is on a level with the surrounding skin, are the result. 
These ulcerations spread and unite until they sometimes form an ulcer 
of considerable extent, and constitute in themselves a serious disease." 1 
These ulcers are gradually covered with a false membrane, which becomes 
organized and covered with epidermis, as the process of healing makes 
progress. The erythematous redness which attacks the ankles and heels 
may also run on into ulceration. These accidents are by no means 
common in private practice, as M. Trousseau has shown that they are 
dependent upon a want of cleanliness, more likely to occur in a hospital. 
Redness and excoriation we do constantly see, however, and with all 
care it is difficult, if not impossible, to prevent it. At an advanced 

1 Mai. des Nouveaux-nes, p. 221. 



524 • DYSENTERY. 

stage of the disease we also not unfrequently find aphthous patches 
around the anus. Prolapse of the gut, also, is by no means uncommon. 

The fever continues; the pulse is quick; the heat of the surface un- 
equal; the extremities often cold; the thirst considerable; the mouth 
hot and dry, often attacked by aphthae, especially at the angles ; there 
is great depression of strength, and extreme emaciation. 

Colitis may terminate fatally at an early period, from the intensity 
of the disease, but more frequently it is protracted for several weeks, 
and the child sinks from exhaustion : or coma and other cerebral symp- 
toms supervene, and carry off the patient. 

The principal complications of dysentery are affections of the mouth, 
such as muguet, aphthae, cancrum oris, &c, and cerebral irritation or 
effusion, just as we found to be the case with diarrhoea and enteritis; 
and the observations I there made apply equally well to the present 
disease. 

758. Chronic Dysentery presents nearly the same array of symptoms, 
but in a minor degree. Frequent discharges of mucus mixed with blood, 
occasionally of faecal matter; uneasiness and pain in the bowels, tenes- 
mus, more or less tension and tenderness of the abdomen; a dry mouth, 
thirst, no appetite, aphthae at the angles of the mouth and about the 
anus; great prostration, extreme emaciation, &c. 

We find cases occur as the partially successful result of treatment, or 
as an effort of the constitution to throw off the disease; but, after re- 
maining in a chronic state for some time, they very frequently prove 
fatal from exhaustion. 

759. Secondary Dysentery is more frequent in the course of the 
eruptive fevers, and the characteristic symptoms show themselves from 
the sixth to the tenth day. There may probably be a diarrhoea for 
some days before, and then the discharges become sanguinolent, either 
black or red, and mixed with mucus. The evacuations are frequent, 
and accompanied with tenesmus. The abdomen is tense, tender and 
generally hot, and the constitutional symptoms very marked, — fever, 
dry, hot skin, anxious distressed countenance, sunken eyes, &c, but 
these may, of course, be partly owing to the primary affection. The 
following is the description of the disease, by M. Constant, in an epi- 
demic which occurred at the Hopital des Enfans: "The disease ordi- 
narily commenced by abdominal pains, accompanied by borborygmi and 
frequent desire to evacuate the bowels. The discharges were scanty, 
passed with great effort, and consisting at first of greenish or yellowish 
viscid mucus, soon replaced by whitish mucus mixed with blood, and 
lastly consisting of arterial blood, either pure or mixed with small quan- 
tities of stercoral matter, or the remains of membraniform concretions. 
At the same time there were griping pain, tenesmus, and pain in the 
rectum and anus; but this latter symptom was wanting in some cases. 
It was only a short time before death that we witnessed coldness of the 
extremities, failure of the pulse, and cadaveric expression of the face. 
In no case was there headache, singing in the ears, stupor, epistaxis, 
lenticular eruption (maculae), sudamina, or the sibilant rale in the chest, 
which so constantly occur in the course of severe fevers. The intellect 



DYSENTERY. 525 

remained intact until the approach of death. In two cases only the 
tongue was dry and loaded." 1 

More than half of the cases referred to by M. Constant died, and all 
Rilliet and Barthez's cases, after an interval of from four to fifteen days 
from the commencement of the diarrhoea, and from three to ten after 
the appearance of the dysenteric symptoms. 2 

760. Morbid Anatomy. — In all cases there is evidence of inflamma- 
tion, often very intense, in the large intestines, and often also in the 
smaller. The mucous membrane is red, swollen, thickened, and of 
slight consistence, often very much softened, with small ecchymoses 
here and there. 

In the great majority of cases the mucous follicles are enlarged, and 
their orifices widened and ulcerated. 

M. Bouchut gives the following result of his observations on young 
infants: "The large intestine was aifected throughout in all cases, but 
the disease was chiefly confined to the mucous membrane. The intes- 
tine was ordinarily contracted, as it had been left by the spasm of the 
muscular coat, and the mucous membrane was of course thrown into a 
number of folds, the edges of which presented marks of inflammation. 
The color of the membrane varied from a pale rose to a bright scarlet, 
interrupted by the enlarged, whitish, prominent mucous crypts, de- 
pressed in the centre, and filled by a grayish fluid. At the edges of 
the folds erosion and ulceration occurred, of an irregular form, super- 
ficial and narrow, with red but not raised edges, and a surface of the 
same color as the surrounding tissue. Ulcerations were also found in 
the intervals of these folds, small, superficial, and round, hardly to be 
distinguished except by their inflamed borders, and probably occupying 
the mucous follicles. In those infants who died quickly the mucous 
membrane was of a marked thickness; but in cases which were pro- 
longed, with great emaciation, it was very thin, and, in some cases, 
scarcely discernible. It was generally softened, especially in those 
cases where the membrane was very red." 

The mucous follicles were always developed, with their orifices gene- 
rally dilated or ulcerated. 

The cellular membrane was somewhat thickened, and slightly harder 
than usual. The muscular tissue was unchanged. The mesenteric glands 
were occasionally enlarged, but unaltered in color or texture. 3 

M. Constant has stated that in all his cases there was false membrane 
on the surface of the large intestine. In all, the mucous membrane was 
of a deep red color, thickened, rough, and unequal in its surface, and 
presenting different degrees of softening. 

Dr. Mayne states that he found an undue degree of vascularity of 
the peritonaeum, congestion of the absorbent glands, thickening and 
induration of the coats of the intestine, the mucous membrane varying 
in color from a bright red to green or purple, in some cases covered 
with a bran-like exudation, in others ulcerated. The ulcers were some- 
times small and isolated, in others superficial and extensive, and, in a 

1 Gazette Me'dicale, 1836, p. 101. 2 Mai. des Enfans, vol. i. p. 530. 

3 Mai. des Nouveaux-nes, p. 210. 



526 DYSENTERY. 

third variety, large, irregular, ragged, and penetrating. The small in- 
testines were generally healthy; the liver was sometimes extremely con- 
gested. 1 

761. Causes. — I do not know that either age or sex have much in- 
fluence in the production of the disease ; it occurs in both sexes indif- 
ferently, and at all ages, especially about the period of dentition. 

Atmospheric influence, however, is clearly traceable ; heat, moisture, 
and impure air seem to be the three principal elements. Thus we find 
it more frequent in the latter part of the summer and beginning of winter. 

The usual exciting causes of diarrhoea will give rise to it ; improper 
food, or an excessive quantity; cold, damp, deficient clothing, dentition, 
&c. 

Moreover in certain localities it is endemic ; foundling hospitals, 
fever houses, the densely populated and badly ventilated parts of towns, 
&c. 

Epidemics of dysentery are by no means unfrequent. I have alluded 
to the one described by Constant in the Hopital des Enfans in 1835. 
Dr. Cogswell described one which prevailed in the state of New York. 3 

My friend, Dr. Mayne, has described an epidemic which prevailed 
in the South Dublin Union Poor-house between April, 1846, and 
August, 1848, during which 127 male children under ten years were 
attacked, and seventy-four died. The disease prevailed equally among 
the female children under Dr. Shannon. In a great many of the cases 
the disease occurred as a sequela of measles, proving rapidly fatal. 

Dysentery may supervene as a secondary affection upon diseases of 
the mouth, chronic diseases of the lungs and skin, and especially in the 
course of measles, scarlatina, and smallpox. 

762. Diagnosis. — The only positive distinction between dysentery 
and diarrhoea, is the presence in the former of small muco-sanguineous 
evacuations with severe tenesmus. In general dysentery is much the 
more severe, with more suffering and decidedly more fever. 

763. Prognosis. — Even as a primary disease the prognosis must of- 
ten be unfavorable, and still more when it supervenes upon a disease 
which has already exhausted the strength and constitution of the 
patient ; in fact, very few of the latter cases recover. In general it is 
very obstinate, not amenable to treatment, and unless seen early and 
treated promptly, it is very apt to wear out the patient, even when not 
of sufficient intensity to destroy life quickly. 

The most favorable symptom is the recurrence of faecal matter in 
the stools, the return of appetite, and the disappearance of fever. 

764. Treatment. — Bearing in mind that there are in all cases evi- 
dences of inflammation of the large intestines, and that often very severe, 
we need not hesitate in primary dysentery to apply leeches along the 
track of the colon, in numbers proportioned to the child's strength and 
the severity of the attack. Some writers have recommended these ap- 
plications to the verge of the anus, but Dr. Condie objects to this, on 
account of the difficulty of stopping the leech-bites occasionally, and I 
quite agree with him. 

1 Dublin Journal, May, 1844, p. 298. 

2 New York Med. Repository, vol. ii. p. 127. 



DYSENTERY. 527 

In secondary colitis the condition of the child generally precludes 
the possibility of applying leeches ; but for this, they would be equally 
suitable. In chronic dysentery they are rarely necessary. 

Bleeding from the arm has been advised when the child is strong, the 
attack severe, and the fever high ; the necessity of the case must of 
course determine its propriety. 

After the leeching nothing will be so comforting as a linseed-meal 
poultice applied hot, and renewed every hour. Fomentations and warm 
baths are also very beneficial. 

There is considerable difference of opinion as to the use of purga- 
tives, and the time for their administration. No doubt there is gene- 
rally an accumulation of faecal matter above the diseased portion of 
the intestines, which must be evacuated ; it is true also that the dis- 
charge of faecal matter is a first symptom of improvement; but I con- 
fess I prefer, as in diarrhoea, quieting the excessive irritation in some 
degree first, and then administering moderate purgatives at intervals. 

We may begin then by a starch and opium enema, or a mucilaginous 
or chalk mixture with laudanum, or acetate of lead and opium, or calo- 
mel, ipecacuanha, and hyoscyamus, or Dover's powder, in doses propor- 
tioned to the age of the child. One-third of a grain of calomel, as 
much ipecacuanha, and one-twelfth of a grain of opium, may be given 
every three or four hours, to a child of a year old; but if the stomach 
be irritable the ipecacuanha must be omitted. 

In the epidemic described by Dr. Mayne no medicine was so useful 
as mercury given early, in small doses rather than large ones, and con- 
tinued until the evacuations exhibited a beneficial change, or until saliva- 
tion occurred. Next to mercury, alkaline medicines were most useful ; 
the liquor potassae, or lime-water, with a small quantity of opium were 
found very soothing. Opium, in full doses, aggravated the disease ; 
purgatives were rarely useful ; the bitartrate of potassa in large doses 
failed ; turpentine was of little use, except in cases of relapse ; and 
ipecacuanha was perfectly ineffectual. 1 

Medicated enemata, as a means of acting locally upon the intestines, 
are strongly advised by M. Trousseau and others. These may be com- 
posed of the acetate of lead, with or without laudanum, sulphate of 
zinc or copper, the ammonide of copper, &c. ; but the one M. Trous- 
seau prefers is the nitrate of silver, in the proportion of one or two 
grains to eight or ten ounces of water, once a day in mild cases, or 
twice a day when the attack is severe. It will be necessary first to clear 
out the bowels with a lavement of warm water, and then throw up the 
solution with the long tube and syringe. 

Dr. West has used gallic acid in an enema ; and in protracted cases, 
when the tenesmus was very distressing, one of black wash containing 
laudanum, or one containing two grains of sulphate of zinc. 

When the irritation is somewhat lessened we must proceed to evacuate 
the bowels, and I do not know a better means than castor oil diffused in 
mucilage, with a few drops of laudanum, as suggested by Dr. Stewart 

1 Dublin Journal, May, 1840, p. 302, et seq. 



528 DYSENTERY. 

and Dr. West. Dr. West's formula for an infant a year old is as fol- 
lows : — 

R.— 01. ricini, gj. 

Pulv. acacias, Qj. 
Syr. simp. gj. 
Tinct. opii, gutt. iv. 
Aquas flor. aurant. gvj. — M. 
A teaspoonful every four hours. 

Or we may give a few grains of rhubarb and magnesia. 

After the acute stage has somewhat passed, a succession of small 
blisters to the abdomen will be found of great service should the attack 
be prolonged; and we may also give some of the vegetable astringents 
recommended in diarrhoea, as being useful as tonics as well as in re- 
straining the discharges. 

" In an epidemic of dysentery that occurred among children in Wash- 
ington county, New York, an infusion of white oak bark, blackberry root, 
and yarrow, in milk, with the addition of sugar, was found, according 
to Dr. Cogswell, to be productive of the best effects." 1 The following 
is the formula employed : — 

R. — Cort. querci alb. 

Rad. rub. villos. aa ^ss. 
Fol. achill. milleflor. gij. 
Coque in lactis, gj. 
A dessertspoonful to be given frequently. 

In the epidemic of 1885, at Paris, the treatment consisted of local 
bloodletting, opiates by the mouth or rectum, and astringents. When 
these failed, or the disease became chronic, a large blister was applied 
to the abdomen. 2 

Dr. J. Cummings, of Mass., U. S., speaks highly of tannin in dysen- 
tery. It may be given along with Dover's powder, or chalk powder, in 
doses of ^ to \ grain three times a day. 3 

The treatment of chronic dysentery is but a modification of what I 
have now laid down : counter-irritation, enemata of lead and opium, 
of nitrate of silver, &c. ; calomel and ipecacuanha, with hyoscyamus or 
Dover's powder, warm baths, &c. 

Williams and others speak very highly of the persesquinitrate of iron, 
&c. 

Dr. Graves, in his excellent work, mentions that he has found the 
pernitrate of considerable use in chronic dysentery in adults ; I do not 
see why it should not be tried with children, though I am not aware of 
its having been given as yet. 4 

765. The child should be warmly clothed with flannel next the skin, 
and should have plenty of fresh, pure air. The diet at first must be 
bland and simple ; mucilaginous fluids and milk and water may be given 

1 Condie, Diseases of Children, p. 244. 

2 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 533. 

3 London Journal of Med., Nov., 1850, p. 1069. 

4 Clinical Medicine, vol. ii. p. 226. 



DYSENTERY. 529 

for drink, and for food, some farinaceous substances in very limited 
quantities. 

After a while, indeed, the diet must be improved, as it will be essen- 
tial to keep up the strength ; and it may be necessary to give wine or 
brandy. Dr. West observes : " As to the time when stimulants are to 
be given, or the quantity in which they are to be employed, no definite 
rule can be laid down. Each case must be treated for itself; and to be 
treated successfully it must be watched most closely. The necessity for 
stimulants may arise suddenly, or the need of their administration may 
be but temporary ; while the infant's state in the morning aifords, in 
cases of severe diarrhoea, no sure criterion to judge what its state will 
,be at night. In general it is not until the active symptoms have begun 
to decline that stimulants are needed, nor even then are they required 
in the larger number of instances." " About half a drachm of brandy 
given every two or three hours to a child of a year old, in a quantity 
of a few drops at a time, mixed with the cold milk and water, or the 
thin arrowroot with which it is fed, will often have the effect of arrest- 
ing the sickness as well as of rallying the sunken energies of the system. 
No stimulant has appeared to answer the required ends better than 
brandy, and, when sufficiently diluted, children take it very readily. 
Sometimes, however, when it has been necessary to continue it for some 
time, it has seemed to occasion pain in the stomach, and even to nauseate 
the child, and in this case the compound tincture of bark, or the aro- 
matic spirits of ammonia, or the two together, may be substituted for 
it ; and there is seldom much difficulty in administering them, if they 
be mixed with milk and sufficiently sweetened." 

Again, " the support of the child's strength is a matter of no less 
importance in chronic dysentery than the suppression of the diarrhoea. 
The great weakness of the patient, and the manifest distaste for nou- 
rishment of all kind, often renders it necessary to continue the use of 
brandy for several days, or even for several weeks. For an infant not 
weaned, there can be no better food than that which is furnished by 
the breast of a healthy nurse. In the majority of cases, however, the 
child has been either in a great measure or altogether weaned before 
the affection came on, and consequently it is a less easy matter to sup- 
ply it with suitable food. Farinaceous articles, such as arrowroot, sago, 
&c. are less easily assimilated in early life than in adult age; and in 
cases of this kind they not unfrequently pass through the alimentary 
canal unchanged. Milk, too, does not always agree, and is sometimes 
ejected almost at once, unless it be given in a state of extreme dilution. 
Under these circumstances, we must not hesitate to give strong beef or 
veal tea in small quantities, but at short intervals, to the patient; for 
though it be true that the bowels are often excited to increased action, 
in cases of chronic diarrhoea or dysentery, by animal broths, yet this 
is a smaller hazard than that of the child dying for want of sufficient 
nourishment." 1 

1 Diseases of Infancy and Childhood, pp. 398, 400. 

34 



530 HELMINTHIASIS, 



CHAPTER XVIII. 

HELMINTHIASIS.— INTESTINAL WORMS. 

766. There is scarcely an attack to which children are liable, nay, 
scarcely a symptom, which has not been attributed to worms, or in some 
way or other connected with them ; and that not only by the people, 
but by medical authorities, with whom, indeed, popular prejudices gene- 
rally originate. Even at the present time, any disease Avhose nature is 
not very clear, any symptom of disorder of the digestive system, or of 
general nutrition, which is obscure, is solved by the magical abracada- 
bra of "worms ;" so that we are in some danger of being driven into 
the opposite extreme, and of supposing them not merely innoxious, but, 
with Roederer and Wagler, and Dr. Butter, rather advantageous. 

It may be as well, therefore, to commence this chapter by stating 
that while I neither deny the existence of worms, nor certain symptoms 
which are coincident with their presence, I very much doubt whether 
any such symptoms are caused by them. These symptoms may be a 
coincidence merely, or they may be the result of an irritation which 
gives rise to worms. Again, I do not believe in the existence of any 
symptoms pathognomonic of worms. Many such have been enumerated, 
but we may meet them all repeatedly without a trace of worms. I 
quite agree with my friend Dr. West, that the only proof of worms 
being present is seeing them. 

Having premised thus much, I shall first notice the varieties of worms 
which have been observed in the intestinal canal, referring my readers 
for more lengthened details to the elaborate researches of Bremser, Ru- 
dolphi, Bellingham, &c. 

767. The ascaris lumbricoides occupies the small intestines princi- 
pally, and is found sometimes in great numbers, occasionally accumu- 
lated in the form of a ball. It is usually from three to twelve inches 
long, and from one to two or three lines in diameter. Its natural color 
is white, but it presents the color of the substances it swallows. It occa- 
sionally finds its way into the stomach, and may be discharged through 
the mouth or nostrils. 

The bothriocephalus latus, tsenia lata, or broad tape-worm, is thinner 
and wider than the common tape-worm, and very long, being often 
twenty feet long. Cases are on record of much greater length ; it is 
said to have been sixty, seventy, or even a hundred feet. Its color is a 
dirty white, though it becomes gray when put in spirits. It has a large 
head, with two lateral grooves, which Rudolphi conceives to be organs 
for the absorption of nourishment. It is an inhabitant of the small 
intestines, and is said to be very common in Poland, Russia, Switzer- 
land, and some parts of France. 



WORMS. 531 

The taenia solium, or common tape-worm, is white and flat ; its ante- 
rior extremity long and slender, with a narrow neck and a minute head, 
armed with four suckers, between which the mouth is situated, sur- 
rounded by a circle of five hooks. The posterior extremity is round, 
and the joints that separate from it are called cucurbitani. It is found 
in the small intestines, where it may attain a great length. There may 
be several together, and occasionally other worms are found along with 
it, according to Rosen. It is not common in very young children, 
although now and then it has been found in the intestines of the foetus. 
Fortassin states that it occurs most frequently in persons engaged in 
preparing materials from fresh animal substances. 

The tricocephalus dispar, or long tliread-ivorm, is probably the most 
common, and is found in the upper portions of the large intestines. It is 
generally from an inch and a half to two inches in length; the anterior 
portion of its body is slender like a hair, and the rest much thicker. It 
is white, or colored by what it has swallowed. Its mouth is at the ca- 
pillary extremity, which is always adherent to the intestine. The sexes 
are in different individuals. The number is almost always small; very 
often only a single one is found. 

The oxyuris vermicularis, or ascaris, or thread-ivorm, is much smaller, 
being from one to four or five lines long, white, slender, and elastic, 
blunt at its anterior end, and with a rounded mouth. It is very com- 
mon in the large intestines of children, and especially in the rectum. It 
is generally found in considerable numbers, imbedded in mucus, and 
often in rounded masses. 

These are the chief intestinal worms : however, Dr. Dewees has 
named several others, as the distoma hepaticum, fluke, or fasciola, the 
scarabseus, or beetle grub, and the oestrus, or bois; and he alludes to 
worms or larvae introduced by accident, and producing spasmodic colic, 
with griping, and occasionally vomiting, or dejection of blood. 

768. Symptoms. — Let us now examine the symptoms which are said 
to precede, accompany, and follow the appearance of worms. Indica- 
tions of gastro-intestinal disturbance generally precede the attack, such 
as disgust for food, loss of appetite, or voracious appetite, or perhaps 
each alternately ; hiccough, dribbling, fetid breath, nausea, acrid eruc- 
tations, sero-mucous vomitings, very acid ; borborygmi, umbilical colic, 
sometimes constipation ; at others, glairy or mucous stools, meteor- 
ism, &C. 1 

These symptoms continue, and to them are added pallor and pufimess 
of the face, softness of the flesh, emaciation and weakness, a slight, 
tickling cough, headache, agitation, sleeplessness, dilatation of the pupils, 
itching of the nose, grinding of the teeth, creeping of the skin, and 
some degree of fever. The stomach and bowels are evidently disor- 
dered, the child complains of a good deal of pain, and of a troublesome 
itching about the anus. The urine may be turbid, yellowish, or whitish, 
like milk and water. Finally worms may be detected in the alvine dis- 
charges. 

M. Legendre has published an analysis of the symptoms produced by 

• Barrier, Mai. de l'Enfance, vol. ii. p. 207. 



532 worms. 

tape-worm in 33 cases. Disorders of the cerebrospinal system occurred 
in 20 cases, swooning in 7, disturbed vision in 6, buzzing in the ears in 
3, and a pricking or gnawing sensation at the epigastrium in 14 cases. 1 
I may also refer my readers to the abstract of a paper by Prof. 
Wawzuch, which gives the result of very extensive experience. 2 

Dr. Horner first noticed an cedematous swelling of the upper lip and 
lower part of the nose, which he regarded as very characteristic ; and 
Dr. Heberden thus sums up the symptoms from which worms may be 
suspected : " Headaches, torpor, vertigo, disturbed dreams, sleep broken 
off by fright and screaming, convulsions, feverishness, thirst, pallid hue, 
bad taste in the mouth, offensive breath, cough, difficult breathing, itch- 
ing of the nostrils, pain in the stomach, nausea, squeamishness, voracity, 
tenesmus, itching of the anus towards night, and dejection of films and 
mucus." 

Now, that we have evidence here of considerable disease of the mucous 
membrane, no one would question ; but upon which symptom could we 
safely rest our diagnosis of the existence of worms, except their pre-' 
sence ? Brera and others consider the face as characteristic ; sometimes 
pale, sometimes flushed, and sometimes of a leaden color, with a dark 
circle under the eyes, which are dull and inexpressive, with tumefied 
nares and upper lip, itching of the nose, and epistaxis. 3 According to 
M. Roman, the tongue has a pathognomonic character, consisting of 
small, prominent, isolated, rough, tubercular points, particularly at the 
edges. The breath is acid, or has a sickly odor, and the saliva is 
abundant. 4 M. Guersent mentions the glairy evacuations mixed with 
blood, and of a greenish-yellow color, with the abdomen sometimes 
tumefied, sometimes flat. 5 Others lay great stress upon the umbilical 
colic, or upon a feeling of constriction in the pharynx. Others, again, 
upon the acceleration and irregularity of the pulse, or upon the nervous 
symptoms. 

Now I do not mean to deny that such symptoms, and many others, 
may occur during an attack of worms, but I do say that we meet them 
all when no worms are present, and that upon them as evidence we 
can place little reliance, and as proofs they are worth nothing. I per- 
fectly agree with Rilliet and Barthez, who, after ample personal expe- 
rience and extensive research, remark: "The examination of our own 
facts, compared with those published by authors, has led us to the con- 
clusion that there is no other pathognomonic sign of the presence of 
worms but their expulsion." 6 When any are expelled it is presumable 
that there are more, although this is only probability, not proof. 7 

769. Suppose we find the symptoms I have enumerated, or a suffi- 
cient number of them, including the decisive one of worms in the eva- 
cuations, are we quite sure that the symptoms are caused by the 
presence of worms ? That similar symptoms may arise from gastro- 
intestinal irritation we know, and may not the worms, when present, be 

1 London Journ. of Med., Nov. 1850, p. 1073. 

2 Ibid., p. 1074. 3 Page 162. 

4 Ann. de la Soc. Med. Prat, de Montpellier, vol. xxii. p. 110. 

6 Diet, de Med., vol. ii. p. 243. 6 Mai. des Enfans, vol. iii. p. 609. 

7 Barrier, Mai. de l'Enfance. vol. ii. p. 206. 



worms. 533 

an accidental and harmless complication, or may they not even be an 
effect of the previous condition of the mucous membrane ? It is a diffi- 
cult question, and one upon which it would be presumptuous to speak 
positively, but I am very much inclined to think that ordinarily worms 
give rise to very few symptoms at all, and that they may probably be 
the consequences of the preceding disorder of the intestinal canal. 

It is right, however, that I should notice some other very inportant 
effects of worms, or what have been supposed to be such. MM. Mon- 
diere 1 and Charcelay 2 have advocated the opinion that worms may perfo- 
rate the intestine during life ; and from having found them in the 
cavity of the peritoneum, Rilliet and Barthez seem to take the same 
view. It is opposed, however, by Rudolphi, Bremser, Scoutetten, Jules 
Cloquet, and Cruveilhier, who remarks that "the worms found in the 
cavity of the peritoneum, or in stercoral abscesses, did not arrive there by 
perforating the intestine, but because it had been perforated previously." 3 

Worms have escaped from, or been discovered in abscesses of the 
abdominal parietes, and it has been supposed that the abscess was the 
result of the perforation and transit of the worms. M. Chailly gives 
an example of a case in a child of two years of age ; and M. Mondiere, 
who has collected and analyzed the facts on record, concludes that the 
abscess may occur in any part of the abdomen, but is more common 
near the umbilicus, or the inguinal canal, and that the symptom which 
marks the passage of the worm is a painful sensation of puncture in one 
particular spot, followed by a colorless swelling, which gradually sup- 
purates. 

M. Charcelay has published a case of fatal hemorrhage from the in- 
testine, in consequence of the division of a small artery by a worm as it 
perforated the intestine. 

Wedekind published an essay on the strangulated hernia occasioned 
by the accumulation of worms; and Rilliet and Barthez regard this sup- 
position as " not irrational," although their researches have not furnished 
them with an incontestible instance. 

Inflammation of the intestine is stated to have been the result of the 
accumulation of worms. 

Dr. Dewees mentions a case in which ninety-six worms, the shortest 
six inches, the longest ten, were discharged at once, forty-five of them 
in one mass. The child previously appeared " in great and constant 
agony." 

Again, intestinal worms have been discovered in other organs. MM. 
Guersent and Tonnelle relate cases of their discovery in the liver ; Hal- 
ler, Arronsohn, Bland, and Tonnelle', of their presence in the air-pas- 
sages, the results of which were sometimes serious or even fatal. They 
have also been found in the nasal canal, the frontal sinus, and the ears. 

Lastly, a series of nervous attacks have been attributed to them ; con- 
vulsions, chorea, pseudo-meningitis, meningitis, &c. 

As I have said, I cannot take upon myself to deny the explanation 
of these occurrences, but I am at liberty to confess that I am not satis- 

1 L'Experience, June 25, 1838. 

2 Recueil de la Soc. Med. d'Indre et Loire, 1839. 
a Diet, de Med. et Clin. Prat., vol. vii. p. 338. 



534 worms. 

fied to attribute these effects to worms; there is too much of the "post 
hoc ergo propter hoc." 

770. Causes. — It would be a useless waste of time and space to enter 
fully upon the qusestio vexata of the origin of worms ; I must refer such 
of my readers as are desirous of fully informing themselves upon the 
subject to the works I have already mentioned. It is sufficient for my 
purpose to say, that one party believe that they or their germs are de- 
rived from without, but that they undergo certain modifications within 
the intestinal canal ; the other party, at once the most numerous and 
most distinguished, that they are entirely formed within the body, 
whether by hereditary derivation or spontaneous generation. 

But what are the causes which favor their production ? Bremser 
thinks that their formation depends upon there being more digested 
than absorbed matter in the intestines, and that from this animalized 
matter vermin have formed. Cruveilhier admits that a superabundance 
of nutrient materials may have something to do with their production. 

It would appear that an hereditary predisposition to worms is trans- 
missible. The age at which they are most frequent is from three to ten 
years, although we meet with them much younger. Between these two 
periods M. Guersent observed them in one-twentieth of the children. 
They are also said to be more frequent with girls than boys, and in 
children of a lymphatic temperament. 

Worms are more prevalent in some countries and in some districts 
than in others; for example, in Savoy and Chambray, in France, 
throughout Holland and Switzerland, in certain parts of Germany and 
Russia. 

Mr. Marshall, Deputy Inspector of Hospitals, observes that Euro- 
peans and Africans are very much subject to worms in India. Mr. 
Annesley states that scarcely one in ten Hindoos is free from worms. 

Moreover, the different species of worms prevail in different localities, 
according to Bremser, Rudolphi, and others ; the bothriocephalus latus 
being more common in Switzerland, Poland, Russia, and some parts of 
France ; and in Egypt, Holland, Germany, and the greater part of 
France, the taenia solium ; the oxyuris and lumbricoides are more fre- 
quent in Great Britain, America, West Indies, and India. 

According to Bremser, worms prevail more in cities than in the coun- 
try, but Dr. Condie has not found this to be the case. 

"it would seem that cold, damp, low, unhealthy situations favor their 
production, and that they are more frequent during the spring and 
autumn than the other seasons. On this account we should expect that 
the children of the poor and wretched would be most afflicted by them, 
and this we find to be the case. 

Do worms occur as an epidemic ? It would appear so from the various 
accounts we have received. 

Worm fever is described by various authors, but it may, I think, be 
resolved into a gastro-enteric fever of the ordinary kind, complicated 
by a discharge of worms, whether essential or accidental, it would be 
hard to say. 

Roederer and Wagler found worms in the intestines of most of those 
who died of the epidemic mucous fever of Gottingen ; and in a similar 



worms. 535 

fever which prevailed at Naples in 1836, Thibault detected worms very 
frequently. 

771. Treatment. — Recollecting what I have said of the little value to 
be placed upon symptoms as indicative of worms, the reader will see 
the importance of ascertaining, as far as possible, by the only sure means, 
whether there be worms, before adopting any specific line of treatment. 
It would be worse than foolish to administer the more powerful reme- 
dies against worms in a case in which we have no proof of their ex- 
istence. But further, as we are not certain that the disorder which is 
undoubtedly present results from the presence of worms, I confess I 
much prefer trying to relieve the distress first, and then, if necessary, 
having recourse to means for destroying and expelling the worms. I 
am happy to have the support of Dr. Condie in this mode of practice. 
He states that " in any supposed verminous case, therefore, we would 
advise that all heating and irritating vermifuges be abstained from, and 
that our treatment be directed chiefly to restore the regular, healthy 
action of the digestive organs, and the strength and vigor of the body 
generally. We have been in the habit of pursuing this plan for a 
number of years, and have seldom been disappointed in promptly and 
effectually curing our patients, and have had but little necessity for 
resorting to either of the articles which strictly appertain to the class 
of anthelmintics. 1 

With this view, the diet of the child should be carefully regulated ; 
not only must it be limited to plain food, but even that must be given 
in smaller quantities than usual, and at regular times. In many cases 
we must be as rigorous in diet as was recommended in the chapter on 
diarrhoaa. But if the irritation be not so great, in addition to bread 
and milk, rice, and arrowroot, we may allow a portion of animal food, 
chicken broth, beef-tea, chicken, or mutton chop. Vegetables, if used 
at all, must be so very moderately ; fruit and confectionery should be 
interdicted. 

Air, exercise, and warm bathing, come next in importance to the 
regulation of the diet, and within reasonable limits should be carefully 
and fully employed. But little medicine may be required. A few 
grains of hyd. c. magnesia, if the bowels are confined ; or hyd. c. creta, 
if free, may be taken two or three times a day. If there be diarrhoea, 
with much intestinal irritation, the remedies already recommended must 
be employed — counter-iritation, poultices, opiates, &c. 

If the bowels are steady, and the tongue pretty clean, I have seen 
good effects from the combination of a bitter tonic and an alkali ; for 
example, two grains of powdered columba root, with as much bicarbonate 
of soda, two or three times a day, for a child two years old. 

772. But supposing that there are no symptoms of gastro-enteric 
irritation or inflammation, or that these have been subdued, and we are 
required to attempt the removal of the worms, "to what medicines 
should we have recourse ?" 

Anthelmintics have been divided into those which succeed by destroy- 
ing the vitality of worms, and those which merely remove them. 

1 Diseases of Children, p. 254. 



586 worms. 

Dewees and others divide them into, 1, those which act medicinally 
upon worms; 2, those which act mechanically ; 3, those which prevent 
the development of their ova or injure the young of the viviparous, or 
act beneficially upon the stomach and bowels. 1 

Among the former we may include turpentine, which may be given 
to very young infants, if mixed with mucilage, milk, almond milk, &c, 
and sweetened. From five to thirty drops may be given three times a 
day, according to the age of the child. It is by no means a pleasant 
medicine, nor will children continue to take it willingly for any time, 
although they may consent to do so for a few days. It may also be 
given in the form of enema, combined with gruel or barley-water, and 
with great benefit, in the case of ascarides in the rectum. 

The dolichos pruriens or cowhage is highly recommended. It should 
be very carefully combined with honey or syrup, and a teaspoonful 
given for two or three mornings, before breakfast ; the last dose being 
followed by a purgative. Its operation seems completely mechanical, the 
minute hairs wounding and irritating the worms ; it is said to be chiefly 
useful against the ascarides and lumbrici. 2 

The fueus helminthocorton is a favorite remedy with French physi- 
cians, and their opinion is confirmed by Dr. James Johnson of London, 
who recommends a strong decoction to be given as an enema. Dr. 
Eberle advises that an ounce of the helminthocorton, with a drachm of 
valerian, should be boiled in a pint of water until reduced to a gill, and 
a teaspoonful given three times a day. He considers it to be not merely 
an excellent vermifuge, but as very useful in that state of the alimentary 
canal which gives rise to worms, particularly when there is want of ap- 
petite and mucous diarrhoea. 3 

" The oleum chenopodii is a remedy in considerable repute with 
American practitioners. We have employed it in some cases with con- 
siderable advantage, as follows : — 

"I£- — Olei chenopodii, gj. 

Sacch. alb. pur., gum acacise, aa 3Jss. M. 
Dein adde aq. menth. sativ. 31JSS. M. 
"A teaspoonful every three hours for two days in succession, to be followed then by a 
dose of castor oil." 4 

Dr. Dewees considers the Spigelia Marilandica (Carolina pink) as 
the most efficacious remedy against lumbrici. He gave the infusion with 
sugar and milk, and in large doses, for three or four days — the last dose 
followed by a brisk cathartic. 

Bremser and Eberle speak highly of the following formula :— 
R. — Sem. santon., fol. tanaceti vulg., contus., ua §ss. 
Ead. valer. pulv. gij. 
Ead. jalap, pulv. £jss. 
Sulph. potass. gij, 

Oxymel scillse, q. s. ut fiat electuarium. 
A teaspoonful to be taken two or three times a day for sis or seven days. 

1 Diseases of Children, p. 493. 

2 Neligan, Medicines and their Uses, p. 20. 

3 On Diseases of Children, p. 266. 

4 Condie, Diseases of Children, p. 256. 



worms. 537 

It is more effectual, however, when so given as to produce consistent 
evacuations rather than watery stools. 

The empyreumatic oil of Chabert is regarded by Bremser, Brera, and 
Rudolphi, as one of our best anthelmintics. From fifteen to twenty 
drops may be taken daily by children from two to seven years old. 

Dr. Vauvert states that flowers of sulphur taken in the morning be- 
fore eating is a most efficacious remedy. 

The Stannum granulatum is recommended by Alston, Patten, Brera, 
&c. Its modus operandi we cannot explain, but it occasions the worms 
to be evacuated. It may be given in doses of from half a drachm to 
two drachms twice a day, in treacle or syrup, with an occasional ca- 
thartic. 1 

" Common salt," Dr. Condie observes, " is, perhaps, one of the best 
anthelmintics we possess ; it has often succeeded in the destruction of 
worms when other remedies have failed. It was a favorite remedy with 
Dr. Rush ; and, whenever we have been able to induce children to take 
it in a sufficient dose, we have never been disappointed in its effects. 
An ordinary sized teaspoonful, dissolved in a wineglassful of water, is 
the proper dose for a child of two or three years old." 

M. Peschier, of Geneva, has strongly recommended the tincture of the 
buds of the male fern (polipodium filix mas); and it is asserted by his 
brother that he cured 150 cases of lumbricoides, tricocephali, and taenia, 
in nine months. 2 

Dr. Fosbrooke obtained great success also with this remedy. The 
dose is from one to ten drops, in pills, or on sugar. 

Dr. West speaks favorably of the decoction of the bark of the pome- 
granate root, in cases of taenia, with an occasional purgative. Many 
other vermifuge remedies have been highly lauded, such as tannin, garlic, 
tin filings, geoffroya inermis, any of which may be tried if those I have 
enumerated should fail. 

Each of these remedies, and many others, have been vaunted as of 
sovereign efficacy in worms ; and yet each will fail, owing, probably, 
as Dewees shows, to the one kind of worm being affected by one anthel- 
mintic, but not by others. Certainly, " that which shall detach and 
expel from the bowels lumbrici shall not stir the taenia solium." We 
must, therefore, endeavor to suit our medicine to the peculiar kind of 
worm. 3 

773. The second class of anthelmintics includes all brisk cathartics 
— calomel, alone or in combination with jalap, scammony, or rhubarb ; 
castor oil, gamboge, and aloes, in the case of ascarides. A full dose 
may be given, and repeated after a day or two, and we shall seldom fail 
to discover a quantity of these little animals in the evacuations. 

In cases of ascarides, the greatest relief is often afforded by injec- 
tions, so as to wash out the rectum completely — the decoction of the 
fucus helminthocorton, turpentine in gruel or water, black wash, solution 
of common salt, aloes, or sulphate of iron, lime-water and milk, assa- 
foetida and milk, olive oil, sulphuret of potash, &c. 

1 Dunglison, Diseases of Stomach and Bowels in Children, p. 60. 

2 Edinb. Monthly Journal, June, 1852, p. 559. 

3 Eberle, Diseases of Children, p. 264, et seq. 



538 JAUNDICE. 

A bougie smeared with mercurial ointment, and passed into the rec- 
tum, is said to destroy these vermin very effectually. 

774. After the worms, or a great portion of them, have been evacu- 
ated, the child will derive great benefit from the exhibition of some tonic. 
Marley recommends the infusion of columba or gentian, with infusion 
of rhubarb, and a little of the compound spirit of ammonia ; Dr. Stokes 
the tincture of aloes, with the sesquichloride of iron ; Dr. Rush, the 
carbonate of iron ; Dr. Dewees, equal parts of the carbonate of iron 
and common salt; M. Cruveilhier, the " wine of quinine" to lymphatic 
children. 



CHAPTER XIX. 



I. JAUNDICE. — II. ENLARGEMENT OF THE LIVER, SPLEEN, ETC. 

775. I have included these subjects in one chapter, not because of 
any necessary or inseparable connection between them, but rather be- 
cause it seemed useless to make several chapters about diseases concern- 
ing which we know so little. 

I shall, therefore, first treat of jaundice in infants and children. I 
do not think it is by any means so rare as some authors have stated. 
If any one will take the trouble to watch an infant for a few days after 
birth, he will find the skin very red for a day or two, then it assumes 
a yellowish tinge, and finally becomes fair. The yellowish tinge varies 
in intensity up to a decided yellow, jaundice color. And in many cases 
I have seen infants continue suffering from this kind of jaundice for some 
days, and then, after suitable treatment, acquire their proper color. 

" In some instances, the skin of the infant will be marked by dull, 
yellow, irregular blotches (maculx hepaticse), more or less extensive, 
and sometimes occupying the greater part of the surface. The color of 
these blotches varies very much in intensity ; and in cases where there 
exists considerable derangement of the alimentary canal, they occa- 
sionally assume a very dark hue (melasina) ; in some instances they are 
accompanied with a prickly or tingling sensation. The disease appears 
to be most generally connected with derangement of the digestive 
organs ; the color of the skin being dependent upon a morbid secre- 
tion from the cutaneous vessels ; it has little or no affinity with jaun- 
dice." 1 

In other cases, the infant is born jaundiced, the skin and conjunc- 
tivae quite yellow : these are not very common instances. 

Or, after acquiring a proper color, the child is attacked by jaundice 
from some of the causes to be noticed presently. 

776. Symptoms. — The symptoms are so characteristic that we can- 
not easily mistake the disease. The skin is yellow, or greenish-yellow ; 
the conjunctivas the same color ; the urine and perspiration contain a 

1 Condie, Diseases of Children, p. 698. 



JAUNDICE. 589 

large quantity of bile, and stain the napkins and shirt of the child 
yellow. The face looks thin, wrinkled, and old ; the appetite is dimin- 
ished ; if very young, the infant sucks feebly, and does not seek after 
the breast. The discharges from the bowels may be dark-colored, if 
the meconium have not been entirely discharged ; afterwards they are 
generally whitish or grayish: in some few cases their color is natural. 
At the commencement of the disease the bowels are generally consti- 
pated ; but I have seen an attack ushered in by diarrhcea, which ordi- 
narily occurs after a few days. 

The tongue has a yellowish-white fur, especially towards the base, 
and the palate occasionally exhibits whitish patches, which resemble 
the false membrane of muguet. 

Vomiting occurs sometimes, even after a moderate meal, but it is by 
no means an invariable accompaniment. There is frequently some 
griping, which the child shows by sudden cries and retraction of the 
limbs. 

The spirits are generally depressed, and the child may be more irrita- 
ble than usual, but I have never seen delirium or convulsions result. 

Such are the ordinary symptoms of jaundice; in the greater num- 
ber of cases there is neither swelling nor tenderness of the abdomen 
or region of the liver, but, in some cases, M. Baumes mentions having 
found the hepatic region swollen and tense. 1 

When the disease assumes a chronic character, it is attended by 
progressive emaciation, tumefaction of the abdomen, sometimes with 
oedema of the lower extremities, or effusion into the peritoneum. The 
tongue becomes dry, and of a dark brown color ; and at an advanced 
stage there are occasionally spots of purpura, or bleeding from the 
mucous membranes. Induration of the cellular tissue also sometimes, 
but rarely, complicates this affection. 

The disease may last from a few days to a fortnight, and then the 
skin acquires its proper color, the bowels become regular, and the appe- 
tite returns. But although, in general, it is a mild disorder, unattended 
by danger, we find that now and then it proves fatal. 

777. Pathology. — It is not easy to explain the occurrence of jaun- 
dice in many cases. It may doubtless arise from some malformation or 
obstruction in the gall-duct, as first described, I believe, by Sir Henry 
Mark in his excellent essay, 2 and I am inclined to think that this is the 
most common cause with young infants. This obstruction may be caused 
by inspissated matter in the duct, or by inflammation of the mucous mem- 
brane extending from the duodenum, as may be the case when jaundice 
supervenes upon diarrhcea. 

Again, congestion and inflammation of the liver may give rise to 
jaundice, although hepatitis is not a frequent disease of childhood. The 
symptoms do not differ much from those already enumerated, except 
that in addition there is a degree of fulness and tenderness of the hepatic 
region. 

We must not forget how important a part the liver has played during 

1 Traits de l'Icterus ou Jaunisse des Enfans de Naissance. 

2 Dublin Hospital Reports, vol. iii. p. 292. 



540 JAUNDICE. 

foetal life, and its undue size at birth ; this disproportionate activity 
previously, and the change to comparative quiescence after birth, may 
have something to do with the liability to the complaint. 

Lastly, jaundice may be caused by organic deterioration of the liver, 
though it is not always present, nor indeed are these diseases very 
frequent in childhood. 

778. Causes. — Various exciting causes have been enumerated. M. 
Anthorn knew jaundice to occur after immersion in cold water. M. 
Levret conceives that the blood remaining in the umbilical vein, after 
it is tied, may become corrupted, and give rise to engorgement of the 
liver and jaundice. M. Andrieu attributes it to pressure of the hands 
of the nurse upon the head of the infant ; but these causes are not very 
probable, to say the least of them. 

The irritation caused by the first attempts at digestion, improper 
food, excess of food, cold, damp, &c, may doubtless give rise to it. Con- 
stipation, by causing an accumulation of bile in the intestines, and its 
absorption, may favor its production according to M. Baumes. 

Dr. West remarks that " the children in whom jaundice is most fre- 
quent and most intense, are the immature and the feeble ; while in none 
is it so often met with, or in such an intense degree, as in infants affected 
with induration of the cellular tissue, in Avhom the yellow color is often 
so deep as to be manifest in the serum infiltrated into their cellular 
tissue, or poured out into the cavities of the chest or abdomen. Inter- 
ruption of the function of the skin and great impairment of that of 
the lungs are, as you know, the grand characteristics of that affection, 
while in many instances of it, the foetal passages are still pervious, and 
the blood circulates in part through the channels which ought to have 
been closed from the time of birth. These facts seem to substantiate 
the opinion entertained by many writers of high authority, that the 
jaundice of children is not clue to any cause seated primarily in the 
liver, but rather to the defective respiration and the impaired perform- 
ance of the function of the skin, of which the hepatic disorder and 
consequent jaundice are but the effects. 1 

I have known it occur near the termination of gastric fever, and its 
nature was evident from the previous intestinal disturbance, the subsi- 
dence of the pulse and heat of skin, although the icteric color of the 
skin and clay colored stools persisted for weeks. 

779. Prognosis. — In those cases which proceed from mechanical ob- 
struction, from irritation extending from the duodenum, or from tempo- 
rary congestion of the liver, the prognosis upon the whole would be 
favorable if we could distinguish them ; after a little time, the disorder 
gradually subsides, and the infant is restored to health. 

Other cases, however, are not so fortunate, and these I apprehend to 
be chiefly those in which the liver is organically affected. The child be- 
comes emaciated and exhausted, the appetite is lost, the bowels are per- 
manently deranged, and the child is gradually worn out ; it may be 
carried off finally by an attack of convulsions. 

Dr. A. B. Campbell has related three fatal cases. In one case the 

1 Diseases of Infancy and Childhood, p. 372. 



JAUNDICE. 541 

gall-duct was obstructed by inspissated bile, and the other two by con- 
genital absence of the hepatic and cystic ducts. 1 The latter kind of 
cases are generally characterized by the occurrence of hemorrhage, 
generally from the umbilical cord, which can only be at most tempo- 
rarily arrested. 

780. Treatment. — For the cases which arise from retention of the 
meconium and accumulation of bile in the intestines, nature has pro- 
vided a mode of cure in the purgative qualities of the early milk ; the 
bowels being cleared, the cause is removed and the child will recover. 
Or if necessary, we may aid this by a dose of purgative medicine, rhu- 
barb, castor oil, or what I have found even better, a single grain of calo- 
mel, repeated every day or every second day. 

If we have reason to suppose that there is irritation or inflammation 
of the duodenum, we must first endeavor to relieve that by fomenta- 
tions, poultices, counter-irritation, and internally by mucilaginous or 
chalk mixtures, with opium, the hyd. c. creta with Dover's powder, &c. 
When the diarrhoea or vomiting is relieved, then we may either continue 
the mercury with chalk, or have recourse to calomel, as the child may 
be able to bear it. 

Should there be enlargement and tenderness in the region of the liver, 
indicative of irritation or inflammation, it may be necessary to have 
recourse to a leech or two, followed by poultices, and afterwards to blis- 
ters, accompanied by the internal administration of calomel or the hyd. 
c. cret&, as the bowels may be able to bear it. 

After the bowels have been regulated, M. Baumes recommends the 
black oxide of iron, the tartrate of iron and potass, or some vegetable 
tonic. 

In the chronic form of the disease, Dr. Condie speaks favorably of 
turpentine, for the relief of the flatulent pains, in doses of from five to 
ten drops every three hours ; at the same time he gives hyoscyamus, 
ipecacuanha, and carbonate of soda, and applies a camphorated mercu- 
rial plaster over the right hypochondrium. He has also found benefit 
occasionally from the alkalies in combination with a weak infusion of 
hops or taraxacum. 

Considerable care should be taken of the diet, especially if there be 
much disturbance of the bowels. The nurse must be changed if there 
be any suspicion that her milk disagrees with the child ; and at a more 
advanced age, nothing but bland, unirritating food should be allowed. 
Milk, arrowroot, panada, &c, will be found most suitable until the 
disease subsides, and then we may have recourse to a more invigorat- 
ing diet. 

781. Enlargement of the Liver, §c. — Comparatively little notice 
has been taken of enlargement of the liver in children ; they are not 
generally noticed in the systematic works, and I am chiefly indebted 
to a valuable monograph of my friend, Dr. Battersby, for the following 
details : 2 — 

Dr. Graves describes hypertrophy of the liver, as "that state in which 

1 Northern Journal of Medicine, August, 1844. 

2 Dublin Journal, May, 1849, p. 308. 



542 JAUNDICE. 

there is an increase of size in the organ, with induration and imperfect 
secretion, but without any remarkable tenderness. This condition in 
children is accompanied with irritability of the digestive organs, fret- 
fulness, emaciation, loss of sleep, and impaired nutrition. It is only a 
form of general cachexy, connected with the scrofulous diathesis, affect- 
ing secretion and nutrition in general, and the digestive and biliary 
systems in particular." 1 

Dr. West has seen cases of what " he believes to be hypertrophy of 
the liver. For the most part they were associated with very obvious 
indications of a scrofulous habit, but on one occasion only was there 
any serious disturbance of the general health, the child, in that instance, 
suffering from very severe diarrhoea, which had succeeded to a state of 
somewhat obstinate constipation." 2 

Rilliet and Barthez mention enlargement of the liver when speaking 
of hepatitis, which they consider very rare, having only seen six cases 
of it : " It commences by a slight febrile movement, accompanied by 
increased thirst and loss of appetite. At the same time, or shortly 
afterwards, an icteric tint is perceived, limited at first to the conjunc- 
tivae, and slight, but soon becoming very marked. The liver then 
augments in volume, passes the ribs, extends to the epigastrium, and 
ascending in the hypochondrium, increases the dulness of that region. 
The tumor is ordinarily indolent, easily circumscribed when the abdo- 
men is soft and flexible, but is defined with difficulty when it is dis- 
tended. At the same time that the jaundice and tumefaction of the 
liver are manifest, the urine becomes changed and of the color of 
beer. The stools were few, liquid, and discolored. At the end of a 
variable time, the febrile movement diminishes and disappears ; thirst 
is no longer felt ; the appetite is recovered. The tumor of the liver, 
which has progressively diminished, still continues ; it, however, soon dis- 
appears. The icteric coloration is in part effaced ; the urine recovers 
its normal color, and at the end of twenty or thirty days all the morbid 
symptoms have disappeared." 3 Of Rilliet and Barthez's six cases, five 
recovered. 

782. Dr. Battersby's cases, in some respects, resemble the foregoing 
description, although the history and results differ considerably. 

He met with sixteen cases, and out of eleven, six died, two of them 
of scarlatina ; four recovered, and one remained under treatment. 

As to the ages, one was under one year; four from one to two years; 
six from two to three years ; one from three to four years ; one from 
four to five years ; and three from six to seven years. 

As to the symptoms, Dr. Battersby observes: "In thirteen there was, 
in general, a slight febrile action, with tenderness on pressure over the 
liver ; in some the stools were uncolored, and the urine was deeply 
tinged. In ten, jaundice existed for some time ; in five, ascites or 
anasarca ; in one, phthisis ; in one, pompholix ; and one was affected 
with laryngismus stridulus. The children were generally languid, 

1 Clinical Medicine, p. 566. 

2 Diseases of Infancy and Childhood, p. 432. 

3 Mai. des Enfans, vol. i. p. 578. 



JAUNDICE. 543 

wasted, and had a dirty, jaundiced hue of countenance. The abdomen 
was much enlarged, its veins were distended, and the liver could be 
most distinctly felt extending, at various degrees of distance, from the 
ribs to the pelvis. In one case only I received intelligence of pain 
being felt in the right shoulder. Instead of the enlargement of the 
liver disappearing in twenty or thirty days, I have seen it after the con- 
tinuance of a year, one year and six months, two years, and even three 
years and a half." In one case clots of black blood were passed by stool 
and vomiting a week before death. 

But the most remarkable symptom, and one which, so far as I know, 
has not been noticed in children as a concomitant of disease of the liver, 
was a depraved appetite, or pica, as it is called. It was observed in 
seven of these cases of enlargement of the liver ; but whether the direct 
result of the disease, or the consequence of some condition of the sto- 
mach induced by the disease, it is not easy to say. "As a general rule," 
Dr. Battersby remarks : " this is one evidence of undue lactation, for 
of fourteen cases in which I noted it, the average duration of suckling 
was twenty months ; six of these cases were suckled two years and 
upwards ; and one of them weaned at one year, was continued at the 
breast for seven months during the utero-gestation of a succeeding 
child. I have remarked that these little children eat greedily of coals, 
cinders, ashes, lime off the walls, dirt, shoes, paper, and even their 
own ordure. Children affected with pica are very delicate and wasted, 
their complexion is sallow, anaemic, and waxy, the abdomen enlarged. 
The bowels are generally too free ; the stools are of all colors, green, 
yellow, black, or white." 

I have seen a case, however, in which this depraved appetite was ap- 
parently hereditary, and unconnected either with nursing or disorder 
of the stomach or liver. 

In two cases the hypertrophy of the liver originated in disease of 
the heart, and in another it was complicated with pleuritis and pericar- 
ditis. 

In the only post-mortem examination given by Dr. Battersby, the 
liver was greatly enlarged, red, and filled with blood, but unaltered in 
structure. 

783. Treatment. — If we see the case early, and have reason to sup- 
pose the existence of active inflammation, or if, at a later period, there 
be much tenderness, the child will derive relief from the application of 
leeches in numbers proportioned to its strength. 

If it be too weak for leeches, or if the symptoms do not demand them, 
counter-irritation by blisters or liniments may be tried. A very good 
plan is to paint the abdomen with tincture of iodine over the region of 
the liver every morning. 

Internally, mercury is the best remedy. It must be given in such a 
form and dose as shall be tolerable to the bowels, and it will scarcely be 
advisable to push its use too far. 

The ioduret of iron acts very beneficially at a more advanced stage 
of the disease. It may be given in syrup, in doses of one-eighth of a 
grain, three times a day, to a child of two years old. 



544 ENLARGEMENT OF THE SPLEEN. 

If the child be a year old it must be weaned immediately, and a good 
nourishing diet allowed ; if under a year, it will probably be advisable 
to change the nurse. 

784. Enlargement of the Spleen. — This disease has hitherto been 
supposed to be peculiar to adults, but Dr. Battersby has observed seven 
cases of it, apparently the consequence of undue lactation. Of six of 
these cases, three died ; it is, therefore, a serious disease. Their ap- 
pearance agrees with the description given by Piorry : " When the 
spleen has been long affected the skin gets a dull aspect ; a grayish 
coloration presenting sufficiently well a light-colored Creole shade, but 
with color less warm and more ashy. It is the integuments of the face, 
especially, where this coloration is most remarkable: It is not the yel- 
low-ochrey color of icterus, nor yet the discoloration of chlorosis ; it is, 
a shade quite special, which has been very ridiculously called bluish 
icterus." 1 

" The conjunctiva is bloodless, and the patients manifest a perfect 
indifference to everything around them. They have a sickly, pallid 
look, and the wasting of the body is not in proportion to the paleness. 
They are truly chlorotic ; they have invariably pica ; the bowels are 
generally irregular ; the abdomen is full. The patient's bulk will 
remain pretty good for a long time, although he will become blanched 
in a state of angemia. The blood is not proper in quality; it is deficient 
in fibrine, and likewise in red particles. The peritoneum sometimes 
becomes affected, and produces ascites, which renders the detection of 
the spleen difficult. The diagnosis is generally very easy, long before 
the spleen has attained a large size. The heart is unaffected in these 
cases. It has been said that the spleen is often hypertrophied in scro- 
fula and rickets; this, however, is by no means an established fact; 
and when there is tumefaction of this organ there is no peculiarity 
about it, and the other viscera, especially the liver, are simultaneously 
engaged." 2 

Dr. West connects enlargement of the spleen with intermittent fever 
and malaria. "The only instance of it," he says, "which I have had 
an opportunity of observing was presented by a little girl six and a 
half years old, who had lived at Fernando Po from the age of two and 
a half years, having had dysentery at three years, and frequent attacks 
of fever subsequently. The enlargement of her spleen had first become 
apparent at five years of age ; and when I first saw her, a few weeks 
after her return from Africa, it had attained so considerable a size that 
her abdomen measured twenty-one and a half inches in circumference. 
The spleen in this case reached from under the ribs quite down into the 
pelvis, and forward as far as the mesial line of the abdomen. Inde- 
pendently of the patient's history, which, in a case of this kind, would 
be of itself sufficient to prevent an erroneous diagnosis, the relations 
of the swelling were characteristic ; for, although situated at the side 
of the abdomen, it did not extend backwards into the lumbar region, 
so as to fill it up completely, as an enlarged kidney would do, but a 

1 Traite de Diagnostique et de Semeiologie, p. 287. 

2 Dr. Battersby, Dublin Journal, May, 1844, p. 318. 



TABES MESENTERICA. 545 

considerable interval existed between the posterior margin of the tumor 
and the vertebral column." 1 

The diagnosis of the enlargement of the liver and spleen is almost 
always easy by an abdominal manipulation, the tumefaction on the right 
or left side being very characteristic, and the dull sound on percussion 
marking as clearly the limits of the tumor. 

I have seen such cases occasionally myself among the ill-fed, ill- 
clothed, and neglected children of the poor. In the better ranks, I do 
not think either disease frequent ; nor can I agree with Dr. West that 
the enlargement of the spleen is necessarily connected with intermittent 
fever, which is rare in Dublin. 

785. Treatment. — The only treatment which Dr. Battersby has found 
of any use is weaning the child when oversuckled, and giving nourishing 
food ; sending it out freely into the open fresh air, and administering 
internally the ioduret of iron, and externally painting the abdomen 
with the tincture of iodine, or friction with the ointment of hydriodate 
of potass. 



CHAPTER XX. 

TABES MESENTERICA. 

1. If the reader will take the trouble of referring to the chapter on 
pulmonary phthisis, he will find that the mesenteric glands were more 
frequently the seat of tubercular deposit than any other organ of the 
body, except the lungs and bronchial glands; that in one hundred cases, 
MM. Rilliet and Barthez found the mesenteric glands affected in forty- 
six. 

This tubercular deposition into the mesenteric glands is the disease 
which has been termed tabes mesenterica, although, as it is generally a 
complicated affection, the description is generally more or less uncer- 
tain, inasmuch as the symptoms essential to tubercle have not always 
been distinguished from those which result from the intestinal or peri- 
toneal irritation or inflammation. 

Among the children of the poor, it is by no means uncommon in 
these countries, though among the richer classes it is comparatively 
rare. Rilliet and Barthez found it in one-sixteenth of all the children. 

Out of 144 cases, twenty-seven were between the ages of one and 
two and a half, forty-one from three to five and a half, fifty-seven from 
six to ten and a half, and twenty-one from eleven to fifteen years of 
age. Of this number, ninety-three were boys and fifty-one girls. 

They further state that the younger the child is the slighter is the 
attack. Dr. Merriman speaks of it as occurring in infants at the breast 
as well as in older children ; but this I must believe to be rarely the 
case. From my own experience, I should say that it is most frequent 

1 Diseases of Infancy and Childhood, p. 436. 

35 



546' TABES MESENTERICA. 

from three or four to eight or ten years of age. M. Barrier remarks 
that it is very common in phthisical children. 

2. Symptoms. — Let me again observe that the symptoms which ac- 
company this disease are not referable simply to the condition of the 
glands, but arise from the intestinal disorder which so generally precedes 
and accompanies the affection, and from certain other more rare com- 
plications of the peritoneum, &c. 

In some cases, however, there is a singular absence of all indications 
of disease, the first discovery being made on examination after death, 
as, for example, in the case related by M. Bayle of a little girl who died 
from a burn, in apparently good health, but in whose mesentery was 
found a dozen tubercles of considerable size in a state of partial suppu- 
ration. Similar cases are mentioned by MM. Morgagni and Guersent, 
and probably most of us have found more or less deposition in these 
glands which had yet attracted no attention during life. 

In other cases, however, the symptoms not only excite suspicion, but 
are at length sufficiently well marked to enable us to determine the 
nature of the essential disease. Probably the earliest symptom which 
excites attention, is a failure in the health and healthy looks of the 
child : it is uneasy, pale, fretful, the appetite diminishes, the bowels 
are disturbed, and it loses flesh. For a time this may be all, and it is 
evident that the cause is disorder of the digestive system, and not 
necessarily tabes mesenterica.. However, sooner or later other symptoms 
are superadded, and the most significant is a dull, deep-seated pain 
about the centre of the abdomen increased by firm pressure, but which 
is not necessarily accompanied by tension or vomiting, nor does it 
resemble the tenderness of peritonitis. It may persist a long time 
without much change, and with no more peculiar characteristics, but, 
according to M. Guersent, it is most remarkable during spring and 
autumn, often diappearing during the heats of summer. 1 

If the bowels be much disturbed, we may have some tympanitic 
enlargement of the abdomen ; at the same time in estimating this, all 
through the disease we must not forget that a child's abdomen is 
naturally somewhat prominent, and disproportionate. At this period 
we shall rarely find any fluid or solid enlargement. 

3. As the disease advances, the symptoms all become aggravated, and 
the constitution deeply suffers. The appetite is variable, sometimes 
slight, in other cases almost voracious, with a desire for depraved food, 
as chalk, earth, &c. in some cases, but this I do not think so com- 
mon as in disease of the pancreas. The bowels are very irregular* 
sometimes constipated, at other times too frequently moved ; the dis- 
charges being frequently slate, or clay colored, or brown, and highly 
offensive. 

The pain in the abdomen continues, or even increases ; sometimes 
there is a tympanitic enlargement, in other cases, but more rarely, 
fluid may be detected. If the abdomen be tense, of course the tumefied 
mesenteric glands cannot be felt ; but if not, we may frequently ascer- 
tain their presence, especially if much deposition have taken place. 

1 Diet, de M6d., in 30 vols., vol. vi. p. 444. 



TABES MESENTERIC!. 547 

MM. Rilliet and Barthez remark upon this subject : " Although the 
tuberculous masses which occupied the glands were often very volumi- 
nous, we were far from being able always to appreciate them by the 
touch. There it was impossible to recognize these tumors when the 
tension of the abdomen was very considerable ; and in other cases in 
which it was less, a repeated and minute examination failed. There 
are, however, cases in which we could ascertain the presence of abdomi- 
nal tumors even though small, but then the abdomen was very flaccid, 
and extremely soft, allowing itself to be depressed even to the vertebral 
column. In other cases, modifications arising from meningitis, facili- 
tated the palpation of the abdomen, and permitted us to recognize the 
tumor in its cavity. In the case of a boy of five years, the abdomen 
was very unequal, knobby, projecting at the hypogastrium, depressed 
at the epigastrium, flaccid and soft. Immediately beneath the umbilicus 
we perceived a tumor which passed the median line on either side a 
finger's breadth and a half. This tumor was very hard, slightly move- 
able, and its tense edge rather sharp. The next day it appeared more 
superficial because of the sinking and softness of the abdominal parietes. 
The superior portion was very movable, but the deeper portion was less 
so. It appeared larger than on the preceding evening, probably be- 
cause we could circumscribe it more completely. On making the 
autopsy, the mesenteric glands formed a mass as large as the fist, com- 
posed of a number of tuberculous glands the size of a small egg. Some 
were entirely tuberculous, in others, tubercular matter occupied the 
centre, and the surrounding glandular tissue was enormously deve- 
loped." 

These distinguished observers further add, that " the abdominal 
tumors, resulting from tubercularization of the mesenteric glands, are 
always situated near the umbilicus ; they are more or less voluminous, 
but generally unequal on their surface; we can perceive that they are 
formed by the agglomeration of a number of tubercular masses. One 
might believe, a priori, that the fixity of the tumor was a constant cha- 
racteristic, but it is not always so ; sometimes, because the glands are not 
sufficiently enlarged to maintain the mesentery immovable against the 
vertebral column ; in other cases because the glands themselves do not 
change their place. But this apparent mobility, according as the ab- 
dominal parietes vary in tension according as the intestines are full or 
empty, affords us varying results, from an examination of the abdomen 
after a few days' interval." 1 

Let me repeat the caution, that the disproportionate size of the abdo- 
men which is remarkable in rickety and scrofulous children, should not 
be mistaken for the enlargement from mesenteric disease. 

With this enlargement of the abdomen, there is a corresponding ema- 
ciation of every other part of the body ; the skin becomes loose and flaccid, 
its color changed to a dirty, sallow hue; the face is wrinkled and the fea- 
tures become sharper, so as to produce a very distressing expression of 
suffering. 

The pulse is permanently quick, but more rapid towards evening, 

1 Mai. des Enfans, vol. iii. p. 443. 



548 TABES MESENTERICA. 

■when a kind of hectic fever sets in, lasting till near morning, and ter- 
minating in profuse sweat. The urine is scanty, and contains an excess 
of phosphates. 

Thus we have disorder of the stomach and bowels, increasing in 
amount and varying in character, deep seated pain in the centre of the 
abdomen, tumefaction of the abdomen by air or fluid, sometimes enlarge- 
ment of the mesenteric glands, and hectic fever. 

4. But we may naturally inquire what are the mechanical or other 
effects of this enlargement and degeneration of the glands ? How far 
it offers an impediment to the circulation through the lymphatics and 
bloodvessels ? Sommering, and other authors, do not believe that the 
lymphatic circulation is injured at all, but that when the glands are 
entirely obstructed, it is completed by the anastomosing branches and 
the chyle thus conducted to the thoracic duct. Barrier, however, sug- 
gests, and I think reasonably, that the defective nutrition in tabes me- 
senterica may be owing partly to this state of the glands. I may add, 
that it may also be owing to the impediment in this situation that we 
sometimes find fluid effused into the peritonial cavity without evidence 
of inflammation. 

It does not appear that the mere pressure of the tumors ever pro- 
duces stoppage of the intestines, although M. Guersent mentions that 
he has known adhesions between the mesentery and the peritoneum 
produce strangulation, or even complete occlusion of the intestines. 

It sometimes happens that an adhesion is formed between the tuber- 
cular mass and the intestines, when the former suppurates, and Rilliet 
and Barthez mention that they have seen the commencement of perfo- 
ration of the intestine at this part. Others mention that through such 
a perforation the softened tubercle is discharged. 

We are told on the authority of Sir A. Cooper, of this tubercular 
matter making its escape by an abscess which burst at the umbilicus, 
and was afterwards cured by adhesive plaster. 1 

When the diseased mass is very large, it is said to give rise not merely 
to ascites, but to anasarca of the lower extremities, from its pressure 
on the veins, especially at an advanced stage of the disease. 

Lastly, the patient is obnoxious to inflammation of the intestines, but 
more especially to chronic peritonitis, partial or general, with its train 
of symptoms to be noticed presently. 

I must not omit to mention also that as tubercles are seldom deposited 
in the mesentery alone we may have a complication of diseases, such as 
tubercular meningitis, bronchial and pulmonary phthisis, &c. &c. 2 

The duration of the disease will depend very much upon the presence 
or absence of these complications. In many cases the disease may go 
on for months before we are quite certain of it, and the child may 
linger until fairly worn out by the hectic fever and want of nutri- 
tion; in other cases the occurrence of enteritis or peritonitis, acute or 
chronic, will hasten the fatal termination. 

5. Morbid Anatomy. — The appearances found on dissection vary a 
good deal, according to the period of the disease, and even at the same 
period. 

1 Coley, Diseases of Children, p. 223. 2 Rilliet and Barthez. 



TABES MESENTERICA. 549 

At an early stage we may find the glands but little, if at all, enlarged, 
of an oblong shape, pale, of a natural color, and with no appearance of 
inflammation. On cutting them open, we discover tubercular matter, 
either in the form of small grains or in larger irregular masses, not 
mixed with nor adhering intimately to the proper tissue of the glands, 
but rather compressing it, and lying between it and the peritoneum. 

Again, the glands may be inflamed, and then they will present a dif- 
ferent appearance, the proper tissue will be found red, enlarged, and 
gorged with blood, more resisting to the scalpel than is natural, and 
increased in volume. The tubercular matter may assume the form of 
rounded or irregular grains, or we may find it, but more rarely, as 
patches, or irregular laminae which insensibly merge into the proper 
glandular structure. 

Whether the glands be inflamed or not, and whether the tubercular 
matter be deposited in their substance or only on the surface, it is some- 
times surrounded by a cyst, more or less distinct; in other cases the 
cellular tissue which surrounds it is gradually confounded with the 
glandular substance, and is partly in contact with the peritoneum, which 
serves to complete a kind of cyst. 

When this mesenteric disease is extreme and of long standing, M. 
Guersent observes that " the glands are often completely destroyed, or 
transformed into isolated or agglomerated masses of tubercle, of differ- 
ent sizes, from that of a pea to that of an egg, in which no trace of 
glandular structure can be detected. The tubercular matter is occa- 
sionally effused between the laminas of the mesentery, and then forms 
patches of greater or less extent, which have sometimes been mistaken 
for a kind of abscess when the tubercular matter was softened. True 
abscesses in this situation are very rare. 

" Mesenteric tubercles undergo all the stages of degeneration to which 
this morbid product is exposed. At first crude, they are of a dull white 
color, or opaline or yellowish. When the tubercular matter is scanty, 
and as it were infiltrated in the tissue of the gland, it is sometimes 
traversed by small, delicate capillary vessels, which subsequently dis- 
appear. In the latter stages we find every degree of softening, from 
a curdy pulp to fluid pus. It is rare, however, to have very fluid pus in 
mesenteric tubercles, either because it is partially absorbed or because 
the patients die before the last change has taken place. We find occa- 
sionally a dry and pasty matter, analogous to what we see in tuberculous 
bronchial glands. 

" At whatever stage the tubercles may have occurred, the peritoneum 
is almost always healthy, transparent, or slightly tinted with a pink 
color. In some few cases it is red, inflamed and adherent to the intes- 
tines." 1 

M. Papavoine mentions a case in which the mesenteric glands were 
converted into greenish-yellow tubercles containing a limpid fluid of the 
same color in the centre. The same author saw in a scrofulous boy, the 
mesenteric glands enormously enlarged, with a central cavity, with un- 
equal parietes containing a deep red opaque fluid, analogous to bile. 2 

1 Diet, de M6d., in 30 vols., vol. vi. p. 437. 

2 Rilliet and Barthez, Mai. des Enfans, vol. iii. p. 407. 



550 TABES MESENTERICA. 

M. Barrier mentions that the changes connected with the peritoneum 
are generally either tubercles, adhesions, or serous or sero-purulent 
effusion. 1 

The mucous membrane of the intestine is not uncommonly red and 
inflamed, especially towards the end of the small intestine, where the 
mucous glands are most largely developed. In some cases we find small, 
round, superficial ulcerations and traces of former ulcers. But besides 
these small ulcerations, there are occasionally deeper ones involving all 
the coats of the intestine and piercing sometimes through the peritoneum. 
These larger ulcers are generally placed circularly and parallel to the 
transverse valves of the intestine. In appearance, they resemble very 
much the ulcers we find in the intestines of phthisical patients. They 
occur, according to M. Guersent, in more than half of the cases of tabes 
mesenterica. 

On the other hand, the mucous membrane is often perfectly healthy, 
even in cases where the glands are the seat of considerable tubercular 
deposition. 

If the child have suffered from chronic peritonitis, we shall of course 
find the usual morbid changes, and the same may be said of the other 
complications, but upon these I need not dwell as I have noticed them 
in detail elsewhere. 

6. Diagnosis. — After a careful analysis of the symptoms of this 
disease, M. Guersent remarks, " it results from this discussion upon the 
physiological characteristics of tabes, that almost all the symptoms which 
have been hitherto assigned to this disease, do not really belong to it, 
but depend upon other affections of the intestinal canal with which it is 
often confounded, because they ordinarily accompany it. The only 
pathognomonic symptom, the only positive character by which tabes 
mesenterica can be recognized in its last stage, is feeling the tubercles 
by the touch : all others are more or less doubtful, and mark the dis- 
orders with which it is complicated." 2 

Although it is true, to a certain extent, that many symptoms have 
been too lightly attributed to this disease which are not essentially con- 
nected with it, and also that but little stress can be laid upon any single 
symptom (except the one) taken alone ; yet I can hardly doubt that we 
may assume the presence of the disease with strong probability from the 
constitution of the patient, the history, the sequence, and combination 
of certain symptoms. 

2. In the earlier stages, it may be quite impossible to decide whether 
the intestinal irritation is connected with tabes or depends upon chronic 
enteritis only, because the two diseases constantly coexist. M. Guer- 
sent mentions that in the former the diarrhoea and pain are increased by 
the slightest errors of diet, but not by movement, whereas in the me- 
senteric disease, the pain is augmented by pressure but not by flatulent 
distension or diarrhoea. Add to this a scrofulous constitution, perhaps 
the presence of tubercles in some other part, the persistence of the 
symptoms, notwithstanding appropriate treatment and unusual dulness 

1 Mai. de l'Enfance, vol. ii. p. 331. 

2 Diet, de MeU, in 30 vols., vol. vi. p. 447. 



TABES MESENTERICA. 551 

on percussion around the umbilicus, and we have ground, I think, for 
suspecting very strongly the presence of this disorder. 

3. The history of the disease will aid us in distinguishing it from 
chronic peritonitis in some cases, but no doubt a degree of obscurity 
will often remain, inasmuch as the two diseases may coexist. 

4. At a more advanced stage when the tumors are perceptible, the 
diagnosis will of course be much more easy and certain, and yet some* 
confusion may arise between them and tubercles of the liver and kid- 
ney. The principal points of difference laid down by MM. Rilliet and 
Barthez are, 1, the seat of the latter tumors in one or other hypochon- 
drium ; 2, by the form of the tumor which terminates in a sharp edge; 
3, by the possibility of pushing back these tumors under the ribs ; 4, 
by the increase of dulness in one or other hypochondrium ; and 5, by 
the absence of tension and distension of the abdomen. 1 

Still, there are some cases in which the diagnostic is and will remain 
very obscure ; and I may say the same of the distinction between pan- 
creatic tumors and mesenteric disease. 

7. Causes. — Whatever causes favor the development of scrofula, 
or tubercle generally, will no doubt aid powerfully in the production of 
mesenteric disease. When the general and local tendency to tubercu- 
lization exists, we can easily understand its being stimulated into 
activity by improper and insufficient food, dirty and badly ventilated 
dwellings, exposure to cold, insufficient clothing, &c. ; but we cannot tell 
why in one person the lungs are affected and in another the abdominal 
organs or the mesenteric glands. 

8. Prognosis. — Nothing can be more serious than the prognosis in 
mesenteric disease, at an advanced stage, when the tumors can be felt. 
Almost all the cases prove fatal, either by gradual exhaustion or by the 
occurrence of some complication. At an early stage, patients recover 
from the intestinal disturbance, &c. ; but then the question arises whe- 
ther the disease was really tabes, and the answer in many cases is very 
doubtful. 

M. Barrier thus states his experience: " The prognosis of tubercular 
affections of the abdomen is at least as grave as that of tubercles of the 
thorax. In fact, the first rarely exist without the second, although the 
latter may occur without the former." "In some cases, abdominal 
phthisis runs its course with great rapidity, especially when the mesen- 
tery, the peritoneum, and the intestines are all affected ; but when these 
are singly affected, their course is slower." " That which proves fatal 
in many cases before the tubercles of the abdomen have completed their 
stages is the coincidence of tubercular affection of the thorax, head, &c, 
or certain local or general complications, as perforation of the intestine 
followed by acute peritonitis, meningitis, eruptive fevers, &c. There is 
no reason, however, to disbelieve in the possibility of a cure, or at least 
of rendering the malady stationary. The cure may take place, 1, by 
the softening and elimination of the tubercular matter; 2, by its trans- 
formation into cretaceous matter ; 3, by its absorption." 2 

1 Mai des Enfans, vol. iii. p. 893. 

2 Mai. de l'Enfance, vol. ii. p. 351. 



552 TABES MESENTERICA. 

Rilliet and Barthez mention a case in which a portion of the tumor 
had been absorbed and the remainder had undergone the cretaceous 
transformation. 1 A similar case has been recorded by Dr. Carswell, 
who states that "the patient, who, when a child, had been affected with 
tabes mesenterica, and also with swelling of the cervical glands, some 
of which ulcerated, died, at the age of twenty-one, of inflammation of the 
uterus, seven days after delivery. Several of the mesenteric glands 
contained a dry cheesy matter, mixed with a chalky looking substance ; 
others were composed of a cretaceous substance ; and a tumor, as large 
as a hen's egg, included within the folds of the peritoneum, and which 
appeared to be the remains of a large agglomerated mass of glands, was 
filled with a substance resembling a mixture of putty and dried mortar, 
moistened with a small quantity of serosity." 

Unfortunately, all these modes of cure are rare, and I fear that the 
true explanation of the many cases of cure which have been recorded is 
to be found in the fact that the disease was really only chronic enteritis 
or gastro-intestinal irritation. 

9. Treatment. — Very much will depend upon the state of the child 
and upon the stage of the disease. 

During the early stage, or when the intestinal irritation is the most 
prominent symptom, our efforts must be directed to quiet that, and to 
regulate the secretions and actions of the bowels. Some of the anodyne 
astringents I have mentioned, when speaking of diarrhoea, if the bowels 
are too free, with perhaps some counter-irritation to the surface, will 
often succeed. 

When the bowels are quiet, the secretions may be corrected by hyd. 
c. creta, combined either with rhubarb or columbo; and, as a change, I 
have seen much benefit from some bitter tonic, as columbo powder and 
an alkali. 

When the bowels are confined, mercurial purgatives are of great use ; 
and many authors lay great stress upon purgatives and emetics as a 
means of removing the disease. This may be the case in the earlier 
stages, but it may well be questioned whether they have this effect, if 
deposition have taken place. 

In some cases, when the abdomen was beginning to enlarge, after I had 
regulated the bowels, 1 found the iodide of iron of great use, in the 
proportion of one grain of the salt to an ounce of syrup ; a teaspoonful 
to be given three times a day, to a child three or four years old. 

It is doubtful in such cases whether the benefit does not altogether 
depend upon the action of the medicine upon the mucous membrane of 
the intestinal canal rather than upon the mesenteric glands. 

All British authorities are agreed, I think, upon the value of mercury 
at some period of the disease, although they differ as to the stage in 
which it is most serviceable. French writers, however, seem very 
doubtful. 

I have not myself had recourse to much mercury in the earlier stage of 
the disease, but Dr. Coley speaks well of its effects. He recommends 
a scruple of the ung. hyd. first to be rubbed ever the abdomen every 

1 Mai. des Enfans, vol. iii. p. 421. 



TABES MESENTEKICA. 553 

night for half an hour, and that the patient should take every night 
from two to four grains of Dover's powder, and three or four grains of 
hyd. c. creta. Every second or third morning, a dose of castor oil is 
to be given, or a grain of calomel and three or four of rhubarb, and 
this treatment must be continued for some time, unless the gums be 
touched. 1 Dr. Merriman advises calomel in large doses at first, and 
then smaller ones for a considerable time when the belly is enlarged, 
until some favorable change takes place in this particular. 

M. Wendt advises a combination of sulphur with calomel in the pro- 
portion of one part to twenty. 

A light bitter tonic has also been found very useful, either alone or 
in combination with an alkali. 

After the deposit of tubercular matter has fairly taken place, or after 
we believe it has done so, the principal remedies are said to be mercury, 
iron, iodine, acetate of potash, &c. &c. sulphur, iodine, or sea baths. 

The mercury may be given in form of calomel, blue pill, or hyd. c. 
creta, or we may have recourse to inunction, and the extent to which it 
should be carried will depend upon the condition of the child and the 
state of the bowels. 

Various preparations of iron have been recommended by different 
writers. The tincture or salt of steel or chalybeate waters are pre- 
pared by Dr. Munn ; others prefer the carbonate or the tincture of the 
muriate, &c. &c. 

The same may be said of iodine, some advise one form, some another ; 
the great point appears to be to guard against any injurious action 
upon the gastro-intestinal tube. 

I have found the iodide of iron in syrup apparently better than either 
element separately. Some prefer Lugol's solution in doses of three to 
six drops three times a day, or the hydriodate of potash in decoction of 
sarsaparilla, adding a minute dose of opium if the bowels be irritable, 
or suspending the medicine altogether. 

As an external application, Dr. Condie advises the iodide of lead 
(5ss to 3j of lard), or the ung. hydriod. potassse. 2 Or the abdomen may 
be rubbed or painted with the tincture. 

Ioduretted baths have been highly recommended ; they are formed by 
dissolving one grain of iodine and two of hydriodate of potash in a 
gallon of water. 

From the benefit derived from cod-liver oil in phthisis, we may natu- 
rally expect similar effects from it in mesenteric disease ; but although 
I have found it useful in some suspected cases, yet they have been too 
undecided and too few to enable me to speak positively, and I have 
not as yet seen any record of an adequate trial of the remedy by any 
one else. 

But as a general rule the success seems very limited; in many cases 
anything like active treatment is injurious, and the utmost we can effect 
is the palliation of the more distressing symptoms. 

Inasmuch as bad air, inferior or innutritious diet, and exposure have 
much to do with predisposing to or producing the disease, our attention 

1 Diseases of Children, p. 226. ' 2 Diseases of Children, p. 627. 



554 PERITONITIS. 

must be carefully directed to these points. Fresh pure air, well venti- 
lated comfortable apartments, and warm clothing, are all absolutely 
necessary. 

Bland, mild food must be selected until the fever and intestinal irri- 
tation subside. A mild diet is generally the best, or arrowroot with 
water or milk. Broths must be given with great caution, and generally 
speaking animal food is objectionable. 

Frequent washing portions of the body, warm or cold baths, will also 
be found very useful, both as prophylactic measures, and also as reme- 
dies if the disease be not too far advanced. 

The indications of treatment for the different complications will be 
found in the respective chapters. 



CHAPTER XXI. 



PERITONITIS. 



786. Inflammation of the peritoneum is a rare, and, when acute, 
a very fatal disease among children, much less frequent than either 
pleurisy or pericarditis, and, if I might judge by my own experience, 
I should add than arachnitis ; but Rilliet and Barthez found it more so 
than the latter. In examining the bodies of children who have died from 
other diseases, it is by no means uncommon to find evidences of pleuritis 
or pericarditis which have been cured, but we scarcely ever find such 
traces in the peritoneum, from which I infer either that the disease is very 
rare, or that it carries off its victim. Rilliet and Barthez met with a 
dozen cases of acute peritonitis. 

In certain seasons it seems more common than in others. I met with 
three cases in one winter within a short time of each other, and judging 
from them, I suspect that cases that are put down as enteritis are as 
frequently peritonitis. 

M. Thore found that acute peritonitis existed in about six per cent. 
of all the infants who died at the Hospice des Enfans trouv^s. 

This affection has been but little noticed by writers upon diseases of 
children. Dr. Romberg, of Berlin, in 1833, published a valuable paper 
upon the subject. 1 Meissner 2 has entered pretty fully into the subject. 
Heyfelder, 3 and Malespini, 4 and Thore, 5 have published some interesting 
papers. 

It is noticed by Drs. Stewart and Condie. 

Peritonitis may be either acute or chronic, the latter occasionally 
being of a scrofulous character, and accompanied with the deposition of 

1 Wochenschrift fur die ges. Heilkunde, 1833, Nos. 17, 18. 

2 Ibid., vol. ii. p. 66. 

3 Studien in Gebiete der Heilwissenschaft, 2, B. D. S. 190. 

4 Archives G6n. de Med., 1840. 

s Archives Gen. de Med., Aug. Sept. 1846. 



PERITONITIS. 555 

tubercular matter on the serous membrane. The disease may be either 
primary or secondary, but much more frequently the latter. 

It may occur before birth, as the researches of Dug&s, Billard, Simp- 
son, &c, have proved, and at any age subsequently. Of M. Thore's 
cases, thirty-five out of fifty-nine were less than a fortnight old, and 
none above ten weeks. 

787. I. Acute Peritonitis. — The attack is generally somewhat sud- 
den, coming on either in the midst of health, or in the course of some other 
disease, and marked by severe abdominal pain, commencing, perhaps, 
at some one part, but quickly spreading over the entire abdomen, and 
greatly increased by any movement. In very young infants it is some- 
times not very well marked at first, but, with very few exceptions, it is 
always present. The pain rapidly becomes very acute, greatly increased 
upon pressure ; the abdomen becomes swollen, tense, and tender; some- 
times dull, sometimes resonant on percussion. After effusion has taken 
place it is always dull. This dulness and tension are general when the 
entire peritoneum is affected, but partial and local, when the peritonitis 
is circumscribed; and at the part affected we may feel a kind of tumor. 
Vomiting, which is so common a symptom in adults, is not general with 
children. Rilliet and Barthez met with it only in two cases. Constipa- 
tion also is very rare ; it is more common to find a diarrhoea, which is 
very distressing, as well on account of the pain which accompanies it, 
as from the efforts necessary, and the disturbance of the child after- 
wards. 

The pulse is small and very quick; the face has an expression of acute 
distress and great suffering ; the tongue is generally moist, but loaded ; 
sometimes clean, sometimes dry and loaded ; there is great thirst, and 
an entire loss of appetite. The skin is hot, and occasionally at the 
commencement there are rigors, but not always. 

The breathing is quick, high, and short, not from any thoracic affec- 
tion, but from the pain caused by the pressure of the descending dia- 
phragm in a fuller inspiration. After effusion has taken place, there 
may be a mechanical impediment to full and free respiration. 

The pain occasioned by any movement gives a sort of fixity to its 
position and to an intolerance of any change of posture. Dressing, 
changing napkins, nay, raising the arm even, will give rise to shrieks 
of agony so acute that a suspicion naturally arises of injury or of 
some affection of the parts, the moving of which gives so much pain. 
This symptom, so significant, should never fail to direct our attention to 
the peritoneum. 

788. In unfavorable cases, these symptoms continue and increase, the 
pulse becomes insensible, the pain intense, the abdomen very large, the 
countenance extremely drawn, the anxiety very great, and death soon 
closes the scene. 

In more favorable cases, when the peritonitis is circumscribed, the 
symptoms diminish in intensity, the tumefaction becomes less and less 
painful, and finally disappears ; the pulse becomes slower, the thirst 
less, the fever subsides, and the digestive functions are restored ; or the 
symptoms, subsiding to a certain extent, may take on a chronic character. 

Another mode of termination occasionally occurs. Dr. West ob- 



556 PERITONITIS. 

serves: 1 "The active symptoms diminish in intensity; the abdominal 
parietes grow thin at some spot, where a passage at length is formed, 
through which pus is discharged, and recovery sometimes slowly fol- 
lows ; the result of a process precisely analogous to that which nature 
has recourse to in pleurisy, when she brings about the evacuation of the 
fluid through an opening spontaneously formed in the parietes of the 
thorax. An instance of this mode of cure of peritonitis in a child seven 
years old was related by Dr. Aldis, at a meeting of the Medico-Chirur- 
gical Society, in November, 1846. 2 A few similar cases may be -found 
in medical journals; 3 and one has come under my own observation in 
the person of a little girl, whose history I formerly related, 4 as afford- 
ing an illustration of that rare affection, inflammation of the sinuses of 
the dura mater." 

The duration of the disease is very variable ; some cases have proved 
fatal in twenty-four hours ; others have continued for weeks. Rilliet 
and Barthez have given us the duration of nine cases : " In two, it 
terminated in one day ; in one, in three days ; in one, in five days ; in 
one, in twenty-six days ; in two, in twenty-six and twenty-seven days ; 
in two, in thirty-six and thirty-seven days. 5 

There is no essential difference between the symptoms of primary 
and secondary peritonitis ; the former is, perhaps, more frequently cir- 
cumscribed, and the latter, supervening upon other serious affections, 
hardly permits a hope of cure. 

789. Morbid Anatomy. — The serous membrane is generally found 
vascular and red, either partially or generally, and principally that 
portion of it which covers the intestines or the appendages. The sub- 
serous cellular membrane or the muscular coat may be infiltrated and 
softened, so as to be easily torn. In almost every case we find either 
liquid secretion poured out into the cavity, or false membranes. Some- 
times the fluid is serous, clear, abundant, and of a lemon color ; in 
other cases it is troubled, and mixed with albuminous flocculi ; or it 
may be purulent matter, thick, yellow, or greenish yellow. The quan- 
tity varies from a cupful to several pints. The purulent matter is 
generally found in the pelvis ; and according to the quantity, the fluid 
will distend the abdominal cavity more or less completely. 

False membranes generally coexist with effusion, slight,' thin, and 
elongated, or in the form of thin, soft, gelatinous layers, of a whitish 
or yellowish color, but seldom very firm or thick ; they unite the con- 
volutions of the intestines, more or less filling up the interstices, and, 
if the disease be prolonged, forming adhesions between different parts, 
and undergoing gradually the same sort of transformation we noticed 
in pleurisy. 

In one-third of M. Thore's cases, evidences of pleurisy were also dis- 
covered. 

1 On Diseases of Infancy and Childhood, p. 416. 

2 Medical Gazette, November, 1846. 

3 Bernhardi in Preuss. Med. Zeitung, No. 10, 1842; and Beyer, Casper's Wochenschrift, 
1842, No. 5. 

4 Lecture vii. p. 81. 6 Mai. des Enfans, vol. i. p. 564. 



PERITONITIS. 557 

790. Cannes. — Any of the ordinary exciting causes of inflammation 
may give rise to peritonitis, exposure to cold or wet, falls, blows, &c. 

Or it may be the consequence of a surgical operation, and occasion- 
ally it follows the perforation of the gall-bladder, the stomach, or intes- 
tines. Thus, Rilliet and Barthez state that in one case it was the re- 
sult of tapping ; in another, of a fall ; in a third, of the rupture of the 
gall-bladder ; in a fourth, of ulceration perforating the intestines. 1 

Again, it may be a secondary attack, occurring in the course of other 
diseases, as ascites, typhoid fever, scarlatina, 2 or tubercles. 

In seventeen out of M. Thore's sixty-three cases, the peritonitis fol- 
lowed on erysipelas, and in four, on phlebitis of the umbilical vein. 

791. Diagnosis.*— I. Acute peritonitis is more likely to be confounded 
with enteritis or entero-colitis than with any other affection ; in both 
thore is pain and tension of the abdomen, with vomiting and diarrhoea ; 
but in peritonitis the pain is far more intense, the tenderness far 
more acute: the aggravation of suffering by the least movement; the 
drawn, anxious face, the quick pulse, and the fluctuation in the abdo- 
men, are unlike the characteristics of enteritis. 

II. The localized peritonitis has some resemblance to the symptoms 
of abscess in the iliac fossa ; but the latter may be distinguished by the 
slowness with which the tumor is formed, its defined and limited seat, 
its progress, the slight degree of fever, and by its final evacuation, in- 
ternally or externally. 

792. Prognosis. — Nothing can be more serious than the prognosis ; 
peritonitis following perforation is almost necessarily fatal. Secondary 
peritonitis is so grave an addition to any other disease, that we can 
hardly hope for the child to escape ; and the same may be said of 
general peritonitis; there is no more mortal disease. The only cases in 
which there is much chance of recovery, are those in which the inflam- 
mation is partial, limited to one spot, and moderate in degree. 

793. Treatment. — The indications of cure are simple enough; the 
only difficulty is to fulfil them. We must first attempt to relieve the 
inflammation by antiphlogistic treatment ; and for this purpose, unless 
the child be greatly exhausted by previous disease, a number- of leeches, 
large in proportion to the age of the child, should be applied to the 
abdomen, or blood taken from the arm. Unless we can thus make an 
impression upon the disease at an early period, there will be little chance 
of success, and therefore we must act promptly and boldly. More 
moderation will be requisite when the disease is secondary and the child 
reduced, but still we must venture to leech, if we would hope to save 
the child, and to repeat the leeching according as the disease requires it 
and the patient will bear it. 

■ After the leeches fall off, a warm, light poultice should be applied, 
and repeated every two hours, if the weight of it do not cause distress, 
in which case we must substitute frequent fomentations. 

Next to bleeding, the most important remedy is mercury, given so as 

1 Mai. des Enfans, vol. i. p. 568. 

2 Stewart, Diseases of Children, p. 263. 



558 PERITONITIS. 

to affect the constitution, as indicated either by tenderness of the gums 
or mercurial diarrhoea. I have generally found frequent small doses of 
calomel better than larger ones, and in conjunction with mercurial in- 
unction more effective than alone. For example, to a child of two years 
old, half a grain of calomel, with a grain of the pulv. cretse c. opio, may 
be given every two or three hours, and at the same time the abdomen 
smeared thickly with ung. hyd. fort., over which the poultice may be 
applied, or the inside of the thighs rubbed with the ointment ; or we 
may adopt Sir B. Brodie's method, and apply a flannel bandage, smeared 
with the ointment, around the thighs or legs. But if diarrhoea be pre- 
sent, we may have to modify this plan, and either diminish the dose of 
calomel or increase the opium, or substitute for it the hyd. c. creta, or 
perhaps content ourselves with the external use of mercury only. 

Next to calomel, perhaps the most useful remedy we possess is opium 
in peritonitis, as Drs. Graves and Stokes have shown ; and although 
more caution will be necessary with children than with adults, yet the 
effects upon the disease are equally satisfactory. It may be given in 
combination with calomel or gray powder, if they can be borne, but if 
not, it may be continued alone, with benefit to the diarrhoea as well as 
the inflammation of the serous membrane. 

If there be obstinate constipation, of course purgatives must be given ; 
but Ave must take care that we do not ourselves render the exhibition of 
calomel impossible by exciting too much action of the bowels. In gene- 
ral, I much prefer trusting to the calomel acting sufficiently upon the 
bowels as well as upon the constitution. Moreover, if the peritonitis 
be the result of perforation of the intestine, it will be of great conse- 
quence to suspend the action of the bowels, and to cause constipation, 
so that instead of purgatives we must give opium and astringents. 

794. But the remedies I have enumerated are not merely calculated 
to fulfil the first indication ; they meet the second, which is to remove 
the results of inflammation, at a more advanced period, by increasing 
absorption ; and the third, that of preventing the further escape of mat- 
ters from the intestines into the cavity of the peritoneum. 

I have said nothing as yet of blisters, because they are unsuitable at 
first ; but, after due leeching, when the first acuteness of the attack is 
over, and, at a later period, when effusion has taken place, they are 
highly useful; and I have found more benefit from small ones repeated 
than from large ones. 

Warm baths are occasionally beneficial, and always soothing, if the 
child be not too weak, 

The diet of the patient in primary peritonitis must be rigorously 
restricted ; a little milk and water or whey, and a little toast, will be 
sufficient. In secondary peritonitis, however, though it must be mode- 
rate, we must have some regard to the exhausted condition of the child, 
and must support the strength, in order that we may have a chance of 
curing the disease. In addition to milk in any form, therefore, we shall 
have to allow weak chicken broth or beef tea. 

795. in. Chronic Peritonitis. — Slight allusions to this form of disease 
may be found in some of the writers on diseases of children, and more 



PERITONITIS. 559 

details by Baron, 1 Abercrombie, 2 Gregory, 3 Billard, Rilliet and Barthez, 
Sir H. Marsh, West, &c. 

M. Billard gives a short notice of chronic peritonitis, and relates the 
following case: — 

" Josephine Perrine, set. ten months, of a good size, but thin and 
spare, had already cut the two incisor teeth of the lower jaw, when she 
was suddenly seized with dyspnoea. The child, usually lively, had 
become morose and fretful. She entered the infirmary on the 22d 
January, 1826. The abdomen was tympanitic, the respiration a little 
difficult, and was indistinctly heard at the upper part of the right side 
of the chest ; the tongue was dry, pulse small, skin burning ; she was 
affected with diarrhoea, consisting of green and mucous faeces. On the 
23d, the diarrhoea became more light colored. On the 24th, the same 
general symptoms, but without fever ; tension of the abdomen, facies 
hippocratica, forehead wrinkled. On the 26th, deglutition difficult, 
retching whenever drinks were given, very feeble. The isthmus of the 
fauces appeared of a bright red. Death took place on the morning of 
the 27th. . 

"Post-mortem Examination. — Body considerably emaciated; gene- 
ral paleness of the integuments; nearly two ounces of yellow serosity 
were found in the abdomen. Numerous and firm adhesions existed be- 
tween the transverse portion of the colon and the great curvature of 
the stomach. Some of the convolutions of the small intestines were 
likewise adherent, but in a less solid manner. The mucous membrane 
of the stomach was of a pale rose color ; that of the small intestine8 
was covered with red striae, and a number of slate-colored spots existed 
in the whole length of the colon, &c." 4 

Sir Henry Marsh published some interesting cases of this disease in 
1843, to which I had the honor to add some supplementary remarks, 
the substance of which is here reproduced. 5 

I shall now shortly detail the first case, which occurred to myself, and 
for the diagnosis and successful treatment of which I am under obliga- 
tion to Sir H. Marsh. 

Mary , set. six, a healthy child, of delicate, fair complexion, fair 

hair, &c, about December, 1840, was observed to be somewhat unwell; 
she suffered from occasional attacks of diarrhoea, which, after a time, 
either subsided or were relieved by the usual remedies. Occasionally, 
she complained of shooting pains through the abdomen, coming on irre- 
gularly, and lasting but a short time, but not accompanied with tender- 
ness or swelling. Her appetite became delicate and fastidious, with 
some thirst. The pulse was scarcely quickened ; her countenance be- 
came pale, and she became thin. Matters continued in much the same 
state for about a month — occasionally attacks of pain and diarrhoea, 
with loss of appetite, &c. — but, after this time, I observed that the ab- 
domen became gradually swollen, with a distinct sense of fluctuation, 

1 On Tubercles, &c, p. 131. 

2 Diseases of the Abdominal Viscera, p. 191. 

3 Med.-Chir. Trans., vol. ii. p. 259. 

4 Mai. des. Enfans, and Trans., by Dr. Stewart, p. 354. 

5 Dublin Journal, March, 1843, p. 1. 



560 PERITONITIS. 

uneasiness on motion, but no pain on pressure. The pulse rose to 130, 
and there was a certain amount of fever, especially in the evening, with 
an occasional rigor. The emaciation had increased, and the other symp- 
toms continued much the same. 

By Sir H. Marsh's advice, hyd. c. creta, gr. ij, P. Jacob, gr. j, was 
given every four hours. The abdomen was well rubbed with ung. hyd. 
fort., and she took a warm bath at bedtime. This treatment was con- 
tinued a fortnight without any manifest improvement, and without the 
constitution being affected by the mercury. The transient pain, the 
swelling with fluctuation, the quick pulse, the fever, with exacerbations 
in the afternoon, and drowsiness, all continued. The appetite was rather 
improved. She had become by this time both thin and weak, was very 
unwilling to exert herself, and complained of abdominal uneasiness upon 
moving about. 

A blister was then applied to the upper part of the abdomen, and 
dressed with ung. hyd. ; frictions with a scruple of the same ointment 
were used twice a day, and the internal medicines omitted. 

Under this treatment she shortly began to amend. The pain re- 
turned less frequently, and at length ceased; the abdomen gradually 
though slowly diminished in size, until fluctuation was no longer per- 
ceptible ; the bowels became regular, the pulse tranquil, the fever dis- 
appeared ; in about six weeks from the commencement of the treatment 
she was convalescent. 

I have since seen several cases of the same kind which were benefited 
by similar treatment. 

796. Chronic scrofulous peritonitis, with effusion, may follow acute 
inflammation, or it may occur without our being able to recognize any 
preceding acute stage, coming on so gradually, in fact, that we may not 
be aware of the nature of the disease until it is fully developed. As M. 
Duges observes, "there may be occasional pains, colics, irregular attacks 
of diarrhoea, emaciation, paleness, for weeks or even months before the 
disease is fully established." 1 

From the earlier and more prominent symptoms being referable to 
the mucous membrane of the intestinal canal, the real affection may be 
overlooked, and the fatal results attributed to the diarrhoea. 

It may also be either primary or secondary, more frequently the latter. 

797. Symptoms. — From what has already been said, it will be 
gathered that the mode of invasion varies widely. In one class of cases 
the patient labors under diarrhoea for a considerable time, with or with- 
out pain ; the appetite is pretty good, the temperature natural, and the 
pulse quiet ; but at length — it may be weeks or months — we hear com- 
plaints of a sensation of pricking, or of paroxysms of pain, and a feeling 
of tightness in the abdomen, which, upon examination, is found to be 
more or less swollen. 

In other cases there is a certain amount of pain from the beginning, 
occurring in paroxysms, with perfect intervals, and though at first 
limited to one part of the abdomen, yet by degrees spreading over and 
occupying the whole. 

1 Diet, de M£d. et de Chir. Prat., toI. xii. p. 295. 



PEEITONITIS. 561 

Again, as Dr. Abercrombie remarks, "in a very important modifi- 
cation of the disease there is no complaint of pain; the patient merely 
speaks of a feeling of distension, -with variable appetite and irregular 
bowels, and with these complaints becomes progressively emaciated. In 
many cases, indeed, the early symptoms are so slight that no attention 
is paid to them until the emaciated appearance of the patient excites 
alarm. The abdomen, on examination, is probably found tumid, and in 
some degree tender in various parts ; and, upon questioning the patient, 
it is found that there has been some degree of pain for weeks and 
months. In other cases there has been no actual pain, but a feeling of 
tenderness, which gives rise to uneasiness on pressure, or when any part 
of the dress is tight over the abdomen ; but in many cases the disease 
steals on to an advanced period without any complaint of tenderness or 
pain." 1 

The observations of M. Andral 2 are confirmatory of Dr. Aber- 
crombie's remarks ; Dr. Gregory, however, states that tenderness on 
pressure is present from the commencement. 3 

So much for the mode of invasion. Sooner or later, in the majority 
of cases, the patient complains of pain, occurring most frequently in 
paroxysms of varying intensity and duration, with intervals of complete 
relief; beginning in some one part of the abdomen, and gradually spread- 
ing over the entire. In the words of Dr. Gregory, " the attacks of acute 
pain occur in paroxysms at first, not oftener perhaps than once or twice 
in a day ; but, as the disease advances, they increase in frequency, and 
at the same time in violence. I have seen them happen as often as 
once in ten or fifteen minutes ; they do not last long, and immediately 
after an attack the child appears lively, as if nothing ailed it." 4 

There is frequently, perhaps generally, a certain amount of tender- 
ness on pressure, especially at the part to which the pain is at first 
limited, though it is not very remarkable in many cases. The patient 
almost always complains of uneasiness on attempting to walk or stand, 
and in some cases finds it impossible to stand erect. 

After an uncertain interval, the patient complains of a feeling of dis- 
tension, and requires the dress to be left loose; and then, if an exami- 
nation be made, the abdomen will be found more or less swollen. Per- 
cussion generally yields a dull sound, but not always, for when the 
bowels are much disordered, they sometimes become tympanitic. 

Fluctuation is, I think, perceptible in all cases, if the examination be 
carefully made ; but it requires especial care with young children to 
guard against the action of the abdominal muscles, and the natural 
elasticity of the integuments. The best mode is to lay the child on its 
back, and accustom it for a short time to the presence of the hand upon 
the abdomen ; then, placing one hand, with the fingers separated, on 
one side, and percussing very gently with the other, the muscles will 
not be excited into action ; and, if fluctuation be perceptible -with the 
second or third finger, we may be certain of the presence of fluid; for 

1 Diseases of the Abdominal Viscera, p. 192. 

2 Mai. de 1' Abdomen, Clin. Med., vol. iii. p. 587. 

3 Med.-Cbir. Trans., vol. ii. p. 263. 4 Ibid., vol. ii. p. 264. 

36 



562 PERITONITIS. 

the pressure of the forefinger upon the skin effectually arrests the vibra- 
tion which results from its elasticity. I have dwelt rather minutely 
upon the mode of examining the abdomen, because in many cases, from 
the paucity and obscurity of the symptoms, our diagnosis must chiefly 
depend upon the presence or absence of fluctuation. 

The enlargement of the abdomen is not always equable; in some 
eases, especially in the commencement, the umbilical region protrudes. 
As the effusion increases, the entire abdomen enlarges, loses its softness, 
and becomes tense and hard, though occasionally unequally so. 

The skin of the abdomen is hot and dry, and has the appearance of 
being stretched and diminished in thickness. In very chronic cases 
large blue veins are visible traversing the abdomen. 

When the mesenteric glands are diseased, it is possible in some cases 
to detect their enlarged condition, by making careful examination at an 
early period, before the abdomen is much distended. 

In some rare cases the intestinal canal preserves its integrity for a 
long time ; the tongue is pretty clean, the appetite much as usual, the 
bowels regular, or perhaps rather constipated ; but in the large majo- 
rity of cases, we find the tongue white, loaded, and flabby; more or 
less thirst; the appetite irregular and fastidious, sometimes increased, 
more frequently impaired or lost altogether; the bowels relaxed or con- 
stipated, perhaps alternately; the stools fetid and of a whity-brown or 
bluish color. " At first," says Dr. Gregory, " the stools are green, 
slimy, or fetid ; but when the disease has existed about six weeks or 
two months, they will be found to consist of a whitish or whitish-brown 
matter, of the consistence of thin pudding; nor do the evacuations 
differ more in quality than they do in quantity from those in health. 
The quantity passed by the child in twenty-four hours, and that with- 
out the aid of medicine, is often enormous ; and I have seen it taken 
notice of by the parents as greatly exceeding what the child could have 
taken in by the mouth." " This state of the bowels frequently con- 
tinues for six weeks or two months, the body of course wasting the 
whole time, until diarrhoea at length comes on, attended with peteehiae, 
which, in the course of three or four days, puts a period to the child's 
life." 1 

When the effusion is considerable, the breathing may be rendered 
rapid and laborious, owing to the pressure upon the diaphragm. There 
may be another cause for the dyspnoea, however, for, as in one of Sir 
H. Marsh's cases, it sometimes happens that the serous membrane of 
the chest is affected, with effusion into its cavity. 

At first the pulse is scarcely altered ; but, as the disease advances, 
it increases in frequency, varying from 100 to 140, but is diminished 
in strength and fulness. The heat of skin is increased. 

In almost all cases, when the disease is fully established and the 
fever marked, there are distinct evening exacerbations of a hectic cha- 
racter, during which the pulse rises, the temperature augments, the 
face is flushed ; there is much thirst, and the urine is high colored, &c. 
After this state has continued an hour or two, it gradually subsides. 

1 Med.-Chir. Trans., vol. ii. p. 265. 



PERITONITIS. 563 

Generally speaking, throughout the course of the disease, the secre- 
tion of urine is diminished in quantity. 

It is hardly necessary to add, that so formidable and long-continued 
a disease is attended with great emaciation and exhaustion. As the 
disease progresses, the local symptoms are aggravated; the quick pulse 
and fever with exacerbations, more remarkable ; the weakness and 
incapability of exertion more extreme ; the patient, in short, is utterly 
worn out. 1 

798. Terminations. — The course of the disease is generally very 
long ; it may be prolonged for several months, and then may terminate 
variously. 

I. In resolution. Under proper treatment the inflammation may be 
subdued, and the effusion absorbed, and this termination is the more 
practicable the less the mesenteric glands are affected. In such cases 
we find the unhealthy condition of the intestinal canal gradually cor- 
rected, the appetite return, and the fecal evacuations become natural ; 
the pulse diminishes in frequency, the fever and exacerbations cease. 
The last symptom remaining is the abdominal distension ; but this, too, 
gradually subsides until fluctuation can no longer be detected. These 
successful cases, however, are not the most common. 

II. In a circumscribed collection of the effused fluid and its final 
evacuation, with more or less subsidence of the original affection. 
Under such circumstances patients have been known to recover. Dr. 
Burns mentions a case of this kind ; 2 and Dr. Abercrombie states that 
the matter may make its way through the abdominal parietes or the 
inguinal ring. 3 An interesting case of this termination was related to 
the Surgical Society, by my friend, Dr. O'Reilly. Such cases, how- 
ever, are very rare. 

in. In death. The majority of cases terminate thus at different 
intervals from the commencement of the attack. Instead of diminish- 
ing, the symptoms progressively increase in intensity. The abdomen 
is very tense and tender, the fever high, the pulse very quick and 
feeble, the thirst considerable, the diarrhoea persistent, the exacerba- 
tions severe, the emaciation and exhaustion extreme. The countenance 
becomes sunken, the extremities cold, the surface covered with a clammy 
sweat, and occasionally dotted with petechise, and, at length, after a 
prolonged period of suffering, death closes the scene. In some cases 
the disease is brought to an earlier termination by ulceration and per- 
foration of the intestines, which convert the chronic peritonitis into 
aeute. 

799. Morbid Anatomy. — Occasionally the vessels of the peritoneum 
are injected, though sparingly ; there is more or less serum effused into 
the abdominal cavity, with shreds of lymph floating therein. 4 The in- 
testines are more or less agglutinated together, and often thus assume 
the appearance of sacs of matter. Where there has been perforation of 
the intestines, we find fecal matter mixed up with the serum, and can 

5 Burns's Midwifery, p. 811. 2 Midwifery, p. 811. 

3 Diseases of the Abdominal Viscera, p. 195. 

* Burns's Midwifery, p. 811. Denis, Mai. des Enfans nouYeaux-ne"s, p. 119. 



584 PERITONITIS. 

generally detect the communication with the intestine through which it 
has passed. The peritoneum itself is often thickened, and coated with 
a layer of lymph; sometimes it is studded with miliary tubercles, or has 
tubercular matter deposited upon it. In some cases the mucous mem- 
brane is intact, in others, ulceration has advanced to different stages. 
The mesenteric glands may be free from disease, or they may be en- 
larged, and contain tubercular matter. 

Dr. Abercrombie states as the result of his experience, that " on dis- 
section the bowels are generally found more or less extensively glued to 
each other, and to the parietes of the abdomen, and the omentum is 
often involved in the disease. There is sometimes ulceration of the 
mucous membrane, and not unfrequently the peritoneum is in many 
places much thickened, and studded with small tubercles ; in some 
cases again there is great thickening of all the coats of the intestines at 
particular parts. In many cases there are left amid the adhering por- 
tions of the intestines, cavities full of purulent matter, which is gene- 
rally of an unhealthy or scrofulous character. There is frequently 
disease of the mesenteric glands of the liver or lungs." 1 

Dr. Gregory observes that, " on cutting through the parietes of the 
abdomen, all traces of abdominal cavity will be wanting. The mesen- 
tery, bowels, and peritoneum lining the parietes, will be found united 
together into one mass. The peritoneum, in all its duplicatures, appears 
thickened, and on cutting through the diseased mass, very large quanti- 
ties of scrofulous matter will be found. The mucous membrane of the 
bowels, particularly of the small intestines, appears ulcerated in various 
places, and at these points of ulceration the convolutions of the intes- 
tines communicate, so that instead of forming one line of canal, as they 
will continue to do even in advanced stages of chronic peritonitis, they 
constitute a mass of tubes communicating freely with each other, and 
with the thickened and ulcerated peritoneal membranes by innumerable 
openings. The matter which will be found both within and without the 
mucous membrane will be observed to correspond exactly with that 
which was passed during life by stool." 2 

800. Causes. — Various exciting causes have been mentioned as giving 
rise to the disease, such as bad diet, cold, privations, excesses, dentition, 
constipation, &c, and doubtless with truth; but nevertheless, in the 
majority of cases, it will be extremely difficult to say exactly what is 
the exciting cause. In the cases which have fallen under my own ob- 
servation, it appeared to be the result of an extension of irritation from 
the intestinal mucous membrane. 

It also occurs as one of the sequelse of febrile diseases, such as scar- 
latina, measles, &c. It may be worth remarking, that none of the 
children in whom it occurred at an early age were born of mothers who 
had suffered from puerperal fever. 

801. Diagnosis. — When pain and swelling of the abdomen, with fluc- 
tuation, are present, the diagnosis will be easy ; but in those cases in 
which there is no pain, and but slight tenderness, with little disorder of 

1 Diseases of the Abdominal Viscera, p. 193. 

2 Med.-Chir. Trans., vol. ii. p. 266. 



PERITONITIS. 565 

the digestive organs, there may be great difficulty. Our principal guide 
is the enlargement of the abdomen, which ultimately always occurs, and 
the fluctuation, which, by a little care, may generally be perceived. 
When there is much dyspnoea, or when the diarrhoea is severe, we must 
be on our guard against supposing the disease limited to the chest or 
mucous membrane of the intestines. We know that both may be seri- 
ously involved, concurrently with the peritoneal membrane. The same 
may be said of the mesenteric glands ; they may also be diseased ; but 
when they are affected alone, we shall find neither the abdominal swell- 
ing (at least to the same extent) nor the fluctuation. 

802. Prognosis. — The prognosis, in the majority of cases, is unfa- 
vorable. Where the peritoneum alone is affected, the patient has cer- 
tainly a chance of recovery; but if the mesenteric glands, or the mucous 
membrane of the intestines, or the pleura, be involved, the case will 
probably terminate unfavorably. 

803. Treatment. — The treatment usually recommended is comprised 
in a few lines — short in proportion to its hopelessness. Leeches to the 
abdomen, fomentations, purgatives, of which calomel forms one of the 
ingredients, alteratives sometimes, tonics, chalybeates, absorbents, &c. 
Such is the catalogue usually given. The question, however, deserves 
a little more detail, inasmuch as a certain number of the cases are 
curable, if we are called in reasonably early. 

General bleeding, I believe I may say, is never required; but when 
the pain is distressing, especially if there be parts of the abdomen tender 
on pressure, we may afford relief by the application of a few leeches; to 
be repeated, if necessary. 

The abdomen should be fomented with a decoction of poppy heads, 
twice a day, or oftener, if the paroxysms of pain be frequent ; or a piece 
of lint wet with laudanum may be laid over the abdomen ; and every 
night, or every other night, the patient should take a warm bath. 

If the bowels be confined, a dose of castor oil, or Gregory's powder, 
must be given occasionally ; but if diarrhoea be present, it may gene- 
rally be checked by the pulv. cretse cum opio, or any other astringent 
combined with an anodyne. Dr. Gregory advises laudanum for this 
purpose. 

But our principal reliance is upon mercury, given so as to affect the 
gums, if possible. I believe that the credit of thus administering mer- 
cury in this disease is due to Sir Henry Marsh, as I have found no allu- 
sion to it in any authority. It may be exhibited internally or by inunc- 
tion ; in many cases the latter is preferable, as when diarrhoea occurs, 
the bowels are too irritable. A scruple of the strong ung. hyd. should 
be gently rubbed in over the abdomen, night and morning, and con- 
tinued until the gums are touched, or the disease shows signs of yielding 
to the treatment. 

Blisters to the abdomen are very useful ; they should be small, and 
applied successively to different parts, and dressed with the blue oint- 
ment. 

Should the disease give way, the moment the febrile action ceases 
will be the proper time to commence the use of tonics ; and the diet, 



566 PERITONITIS. 

which up to this time should be bland and unstimulating, though nutri- 
tious, may consist of broths, meat, and a moderate quantity of wine or 
porter. 

During convalescence the patient must be confined to the house at 
first, and only by degrees allowed to take air and exercise. The cloth- 
ing should be warm, with flannel next the skin. At a more advanced 
period of convalescence a removal to the country will be of essential 
benefit. 



SECTION V. 



DISEASES OF THE SKIN. 



804. My object in the present section is simply to give a brief sketch 
of those eruptions which occur most frequently in children. Although 
I agree with those who object to many points of the classification of 
Dr. Bateman, yet, in order to avoid confusion, I think it better to make 
use of his terminology, and, to a great extent, of his arrangement, 
specifying any points of difference as they arise. 

That the varieties of cutaneous eruptions are caused by the difference 
of the tissues involved, and the varying amount of inflammation, I fully 
believe, with perhaps one exception — and with regard to that the ques- 
tion can hardly be considered as settled. 

Commencing, therefore, with the slightest of these diseases, we shall 
consider successively the papular, squamous, vesicular, and pustular dis- 
eases in order. For fuller details I must refer my readers to the works 
quoted below. 1 



CHAPTER I. 

STROPHULUS. — PRURIGO. — PITYRIASIS. — ROSEOLA. 
I. STROPHULUS, OR RED GUM. 

805. This is ordinarily the earliest eruption to which infants are 
liable : it is very commonly seen a day or two after birth, and from 
time to time during the first year of infantile life. It appears to' arise 
from the irritability of the skin, and its sensibility to reflex irritations; 
thus, at an early period, it seems to be owing to the assumption of their 
proper functions by the stomach and intestinal canal ; at a later period, 
to some disorder of these organs, or to dentition, &c. 

Willan and Bateman have described five varieties : the strophulus 

1 Willan on Diseases of the Skin. Bateman on Cutaneous Diseases. Britt, Abrege 
pratique sur les Maladies de la Peau, by Cazenave and Stredel. Lecons sur les Mai. de 
la Peau, par P. L. A. Cazenave. Eruptions of the Face, Head, and Hands, by Dr. Bur- 
gess. Portraits of the Diseases of the Scalp, by W. C. Dendy. On Diseases of the skin, 
by Dr. Neligan. 



568 PRURIGO. 

intertlnctus " is characterized by papulae of a vivid red color, situated 
most commonly on the cheeks, forearms, and back of the hands, 
but sometimes universally diffused. They are usually distinct from 
each other, but are intermixed with red clots or stigmata, and often with 
larger red patches, which have no elevation. Occasionally a few small 
vesicles appear on the hands and feet, but these soon desiccate without 
breaking." 1 

The other varieties are mere modifications of this one ; sometimes we 
find minute, hard, whitish, elevated specks mixed with it {strophulus 
albidus) ; or the eruption is more extensive and general, of a more vivid 
red, and sometimes in large, irregular patches (s. confertus) ; or it 
occurs in small circular patches or clusters of papulae, arising and exfo- 
liating on different parts of the body (s. volaticus); or it may consist of 
large papulae, with a smooth shining surface, without inflammation, 
around the bases (s. candidus). 

806. Very little treatment is necessary, and no local applications 
beyond daily and careful ablution, or an occasional warm bath. In 
young infants, as the digestive system becomes used to the exercise of 
its functions, less and less cutaneous irritation of the skin is excited, 
and the disease subsides of itself. 

When it proceeds from morbid irritation of the bowels, however, it 
will be relieved by a few grains of gray powder, with rhubarb; or, if 
the bowels are too free, a little chalk mixture, with a drop or two of 
laudanum to the ounce. 

If the teeth are troublesome, and the gums swollen or inflamed, it will 
be necessary to lance them freely, so as to remove the distress. 



II. PRURIGO. 

807. This disease is characterized by an eruption of papulae of the 
same color with the surrounding cuticle, accompanied with severe itch- 
ing. There is but one variety, the Prurigo ?nitis, which frequently 
affects young persons. It is " accompanied by soft, smooth papulae, 
somewhat larger and less acuminated than those of lichen, and seldom 
appearing red and inflamed, except from violent friction; hence an in- 
attentive observer may overlook the papulae altogether, more especially 
as a number of small, thin, black scabs are here and there conspicuous, 
and arrest his attention. These originate from the concretion of a little 
watery humor, mixed with blood, which oozes out when the tops of the 
papulae are removed by the violent rubbing or scratching which the 
severe itching demands. This constant friction also sometimes produces 
inflamed pustules, which are merely accidental, however, when they 
occur at an early period of the complaint. The itching is much aggra- 
vated both by sudden exposure to the air and by heat ; whence it is 
particularly distressing when the patient undresses himself, and often 
prevents sleep for several hours after he gets into bed." 2 

1 Bateman on Cutaneous Diseases, p. 2. 2 Ibid., p. 15. 



PITYRIASIS. 569 

It appears to be most frequent in spring or the beginning of summer, 
and certainly with children occasions great distress. It is quite distinct 
from scabies or itch, and yet, if neglected, it is quite possible that it 
may degenerate into that complaint. 

808. Treatment. — The tepid bath, or frequent ablution 'with warm 
water, appears to be almost the only local remedy necessary, though at 
first the disease seems rather aggravated than relieved. I have found 
the addition of sulphuret of potash to the warm water afford great relief 
to the itching, but I think the most effectual remedy for it is the zinc 
cream, which consists of white wax 4 oz.; spermaceti 4 drachms; almond 
oil and distilled water 16 oz.; otto of roses one drachm, and oxide of zinc 
16 drachms. The wax, spermaceti, and oil should be melted together 
in a water bath, and poured still hot into a mortar previousy heated, and 
the water added by degrees, whilst the mixture is assiduously beaten 
with a twig until it assumes a granulated appearance. The oxide of 
zinc finely powdered may then be added, and the otto of roses. I have 
given this formula in full, because I have found the cream afford great 
relief from the itching in all the eruptions of children in measles, scar- 
latina, &c. Internally Dr. Bateman recommends the use of sulphur, 
alone or combined with soda or nitre, and that this should be followed 
by the mineral acids. 

We must take care to regulate the bowels ; if they are not too free, 
the hyd. c. cretai, with rhubarb and a little carbonate of soda, will act 
kindly and beneficially. . 



II. PITYRIASIS. 

This eruption is characterized by irregular patches of thin scales, 
which exfoliate and reform, but which neither form crusts nor are ac- 
companied with excoriation. The first variety of Bateman [p. capitis) 
is that with which we have chiefly to do. It is observed on the head of 
many, if not most infants, in the form of dandriff, as it is called, and 
appears rather as an excess of cutaneous secretion than as a disease. It 
is most common on the top of the head, but it often extends to the 
forehead, where we may see a band of small whitish scales, easily re- 
moved by friction ; but on the top of the head and at the occiput the 
scales are larger, and, if neglected, rather resemble a large, dirty patch. 
Among the poor this state of the scalp is almost universal, and, I do 
not doubt, forms an appropriate preparation for more troublesome erup- 
tions in that region. Even with infants who are carefully tended, it 
requires patience and constant watching to prevent the formation of a 
layer of scaly secretion. 

Dr. Neligan remarks : " If we examine the condition of the scalp in 
pityriasis capitis, the surface is found to be closely covered with the 
imbricated scales, with small intervals here and there ; the skin of the 
unaffected parts presenting a smoother or more polished appearance 
than natural. On removing one of the scales we find that the spot on 
which it is seated is soft, and that another fine scale may be removed 
from it; and it is not until after the removal of several scales, each 



570 ROSEOLA. 

finer than the preceding, that we arrive at the reddened and inflamed 
surface of the scalp, which is somewhat depressed." 1 

The principal annoyance which it occasions is the itching ; and the 
efforts of the infant of course tend to increase the inflammation and 
irritation. 

809. Treatment. — Daily and careful ablution of the head is neces- 
sary with all infants, and especially when this disposition to excessive 
secretion is manifest ; but I have certainly seen this disease aggravated 
by the frequency and profuse use of soap, which acts as an irritant to 
the tender skin of the infant. Very little, if any, soap should be used; 
if warm or cold water be not sufficient, oatmeal and water, or a little 
of the yelk of egg, may be employed ; and after the head is dry a 
small quantity of very thin oil may be applied ; or, if the skin appear 
red, a lotion of almond milk (Siv) and acetate of lead (gr. xij). 

For the ordinary dandriff, or for this disease, when it has so far sub- 
sided, I have found a lotion of two drachms of borax to a pint of water 
very useful. 

At a more advanced age soap may be used more freely, followed by 
the same oily or soothing applications, or an alkaline or spirituous 
lotion, according to circumstances. It will be generally advisable to 
remove the hair, or to keep it very short, and especially if its growth 
appear to have been injured. 



IV. ROSEOLA. 

810. This eruption is a rose-colored efflorescence, not contagious, and 
without either wheals or papulse. Bateman describes seven varieties ; 
but we are principally concerned with two of them, the roseola autuni- 
nalis, which " occurs in children in the autumn, in distinct circular or 
oval patches, which gradually increase to about the size of a shilling, 
and are of a dark, damask-rose hue ; they appear chiefly on the arms, 
and continue about a week, sometimes terminating by desquamation : 
there is little itching, tingling, or constitutional affection connected 
with this efflorescence, and its decline seems to be expedited by the use 
of sulphuric acid internally :" and the roseola infantilis, which is a 
closer rash, with fewer interstices, sometimes disappearing after a few 
hours, or recurring and disappearing for days together, occupying some- 
times a limited space, in other cases being very general, and accompa- 
nied with smart though temporary febrile action. It appears to be the 
result of intestinal irritation, or of dentition, and it is not uncommon in 
the course of fevers. Previous to the eruption of smallpox, there is an 
eruption of roseola, and a similar one after vaccination ; but these are 
of trifling importance, and indeed I should hardly have mentioned 
roseola at all but for its resemblance to measles or scarlatina in some 
cases, but particularly to measles. I have no doubt but that some of 
the eases, in which it is supposed that measles or scarlatina has occurred 
twice in the same child, were in one instance cases of roseola. 

1 Dublin Journal, August, 1848, p. 41. 



HERPES. 571 

There is sometimes considerable febrile action before the eruption, 
and the eruption may present a striking resemblance to either of these 
diseases ; but in general the fever is infinitely less, and the eruption 
dies away much sooner. Moreover, there is less lachrymation and 
suffusion of the eyes, rarely any bronchitic affection or sore throat ; 
and, finally, it does not run through the family. 

811. Treatment. — The removal of the irritation, caused by dentition 
or disordered stomach and bowels, is in general quite sufficient to cure 
the affection, which, in itself, is of no moment. 



CHAPTER II. 

HERPES. — ECZEMA. — RUPIA. 
I. HERPES. 

812. We now pass on to a different class of diseases, in which the 
cuticle is not merely prominent, but in which it is separated from the 
cutis, and raised above the level of the surrounding parts by the effu- 
sion of serum. The characters of a vesicle, as distinguished from a 
pustule, are thus stated by Bateman: "It is a small orbicular elevation 
of the cuticle, containing lymph, which is sometimes clear and colorless, 
but often opaque and whitish, or pearl-colored. It is succeeded either 
by scurf or by a laminated scab." 

Of that form of disease which I shall first notice, herpes, Dr. Bate- 
man makes five varieties : H. phlyctenodes, H. zoster, H. arcuatus, II. 
labialis, and H. prseputialis: but as the majority of these affect children 
only incidentally, I shall enter into details concerning one species only, 
the herpes arcuatus or ringworm, which Dr. Neligan considers to be 
the true ringworm of the scalp. As we generally see it, it appears in 
small circular patches, with the vesicles best marked at the circum- 
ference; but this I believe to be because the disease, which commences 
by a single small vesicle, spreads concentrically, the centre healing 
whilst the circumference spreads and enlarges by successive crops of 
vesicles, producing in a short time the appearance of a ring. The vesi- 
cles are very minute, and in the course of a week form scabs, which fall 
off, leaving the cuticle underneath red for some time. Fresh vesicles 
may form, dry up, and the scabs fall; or the original circles may re- 
main red, and the cuticle throw off scales merely. 

Other circles meanwhile may form, and thus spread on the upper 
part of the body, the arms, chest, back, face, and scalp. 

There is no febrile disturbance attendant upon this eruption, nor any 
inconvenience beyond a disagreeable itching and tingling in the patches. 

818. Dr. Bateman has noticed another form of herpes, "in which 
the whole area of the circles is covered with close-set vesicles, and the 
whole is surrounded by a circular inflamed border. The vesicles are of 



572 ECZEMA. 

a considerable size, and filled with transparent lymph. The pain, heat, 
and irritation in the part are very distressing, and there is often a con- 
siderable constitutional disturbance accompanying the eruption. One 
cluster forms after another in rapid succession on the face, arms, and 
neck, and sometimes, on the day following, on the trunk and lower 
limbs. The pain, feverishness, and inquietude do not abate till the 
sixth day of the eruption, when the vesicles flatten, and the eruption 
subsides. On the ninth and tenth days a scabby crust begins to form 
on some, while others dry and exfoliate ; the whole disease terminating 
about the fifteenth day." 

Dr. Bateman seems to doubt whether herpetic ringworm is contagious, 
because the other herpetic eruptions are not. . 

M. Biett lays great stress upon its not being contagious, upon its 
vesicular character, and upon its not injuring the hair, as distinguish- 
ing it from porrigo scutulata. 1 

Dr. Neligan has no doubt of its contagiousness; he regards it as com- 
pletely proved as that of smallpox. 

It certainly attacks more than one member of a family or school con- 
secutively, and in some cases I have thought was undoubtedly commu- 
nicated from one child to another. 

814. Treatment. — The hair must be cut short, and if there be much 
irritation, soothing applications are to be applied; if not we may at 
once apply our special remedies. Strong astringent applications seem 
to be the best: the solution of the salts of iron, copper, zinc, or of borax, 
alum, &c, are very successful. The tincture of the muriate of iron I 
have found very useful: the tincture of iodine or nitrate of silver will 
cure it equally well. 

Common ink (which contains sulphate of iron, and galls) is a very 
favorite popular remedy. 

M. Biett speaks highly of lotions of carbonate of soda or potash; 
and his experience is confirmed by Dr. Neligan, who recommends the 
use of both ointment and lotion of these alkalies; and if a more stimu- 
lant treatment be necessary, a dilute citrine ointment. 

The stomach and bowels should be carefully regulated, and the skin 
kept in a state of great cleanliness. 



II. ECZEMA. 

815. The varieties of eczema described by Dr. Bateman are not at 
all peculiar to children, and are not mentioned as attacking the scalp. 
But my friend, Dr. Neligan, has described a disease under the name 
eczema capitis, which is by no means uncommon. It is essentially a 
vesicular eruption, but in the different stages it presents varied appear- 
ances, because probably of the increase of the inflammation from rub- 
bing, scratching, &c, so that it often resembles the eczema impetigi- 
nodes of Willan and Bateman, an intermediate stage between a vesicular 
and pustular disease. 

1 Mai. de la Peau, by Cazenave and Shedel, p. 110. 



ECZEMA. 578 

The appearance of the eruption is preceded by itching, tingling, and 
heat; then the minute vesicles are seen crowded together in irregular 
patches, or scattered over a large surface. They usually appear first 
behind the ear, close to the edge of the scalp, from "whence they spread 
over the ear itself and the scalp. "The interspaces between the vesi- 
cles and the whole of the scalp, on which they are seated, is red and 
inflamed; in most cases the vesicles are so minute as to be scarcely 
recognizable, or at least are not seen by the physician, until they have 
burst, and given exit to a copious exudation of a serous fluid, by which 
the roots of the hair are cemented together. In the acute form of the 
disease the serous exudation continues for a long time, and is a most 
troublesome symptom : but in the chronic forms — and some cases assume 
a chronic character almost from the first — it rapidly dries into furfura- 
ceous scales, which are pushed forward by the hairs as they grow. With 
the progress of the affection, the appearance of the diseased surface 
varies much ; sometimes it is scarcely, if at all, elevated above the 
healthy parts, and is only to be recognized by the watery exudation 
which keeps the hairs in a constantly moist state. In other cases, the 
scalp is raw or excoriated, and secretes a thin whitish pus, which dries 
into grayish-brown scabs, presenting cracks or fissures through which 
the inflamed surface is seen. In a third form of the disease, the serous 
exudation dries rapidly into extremely thin membranous scales, which 
are readily removable by the slightest friction, but cause much itch- 
ing ; and a fourth variety is characterized by a repeated eruption of 
minute patches of vesicles, the patches rarely exceeding the size of a 
small bean, all on the scalp, which pass through the stages of eczema, 
as witnessed on other parts of the cuticular surface, and disappear in 
seven or eight days, but to be rapidly succeeded by a fresh outbreak of 
the disease." 1 

So long as the surface of the cutis remains unbroken, the hair is un- 
injured ; but when the inflammation involves the roots of the hair, or 
ulceration of the cutis destroys them, the hair is either weakened in its 
growth or altogether obliterated. 

Eczema does not appear to be a contagious disease, nor can we name 
any special cause for it ; it may be connected with dentition or intes- 
tinal irritation like other eruptions. 

816. Treatment. — I quite agree with Dr. Neligan that more harm 
than good is done by shaving the scalp, at least in the acute stage of 
any eruptive disorder. The hair should be cut very close with a pair 
of fine scissors, and kept very short ; this occasions no irritation, and 
affords sufficient facility for applying remedies, and for keeping the 
head clean. In no severe or acute case, however, should the head be 
washed with soap ; water alone, or oatmeal and water, will be sufficient. 
The local treatment will, in the first instance, depend upon the amount 
of inflammation : if this be great, the first object is to soothe and 
lessen it by emollient applications, such as poultices, fomentations, or 
the warm-water dressing. When the surface is less red and angry 
looking, we may try the alkaline applications recommended by Biett 

1 Dublin Journal, August, 1848, p. 37. 



574 rupia. 

and Neligan — the carbonates of soda or potash, either in the form of 
ointment or lotion. I would wish to impress upon my junior readers 
the fact that with some children greasy applications altogether disagree, 
and seem to aggravate the eruption, whilst, with the same children, the 
same remedies in the form of lotion will succeed perfectly ; and as this 
can be known only on trial, we should change the vehicle if we do not 
find it answer, before deciding against the remedy. Dr. Neligan forms 
the ointment of either carbonate by adding from twenty to thirty grains 
to an ounce of lard, and the lotion by dissolving half a drachm in a 
pint of rose-water or distilled water. The ointment is to be applied 
three times a day, and should be washed off every morning with the 
lotion : if the lotion only be used, it should be applied five or six times 
a day. The carbonate of soda is preferable when there is much inflam- 
mation, as being less irritating than the carbonate of potash. In all 
cases, Dr. Neligan keeps the child on milk diet during the entire period 
of treatment. 

Dr. Burgess recommends the alkaline lotions instead of any greasy 
applications, but as he regards eczema as a constitutional and not a 
local affection, he lays great stress upon "restoring the tone of the sys- 
tem by means of a course of mild tonics and alteratives." If the secre- 
tion be abundant, and the parts irritated, he advises barley water with 
sulphuric acid (half a drachm of the former to a pint of the latter), com- 
mencing with small doses, and taking a little water after each until the 
stomach is accustomed to the acidulated drink. If these remedies fail, 
then we may try alteratives, as sarsaparilla, and hydriodate of potash ; 
active purgatives if the patient be strong ; and lotions of the nitrate of 
silver, or the bichloride of mercury. 

In chronic cases, where some stimulant is required, a very dilute 
citrine ointment may be used. 1 

• I have found singular benefit in all the moist eruptions, where the 
inflammation is not too great, from the use of black wash ; it dries the 
surface, and forms scabs, which must be carefully removed, in order 
that the lotion may get at the diseased surface. In some cases, a lotion 
of acetate of lead in almond-milk, or decoction of poppy-heads, is very 
soothing. 

The bowels must be regulated, and in some obstinate cases a few 
alternative doses of mercury may be advantageously given. M. Biett 
recommends acid drinks. 



III. RUPIA. 

817. Dr. Bateman states that " rupia is characterized by an appear- 
ance of broad and flattish vesicles in different parts of the body, which 
do not become confluent ; they are slightly inflamed at the base, slow in 
their progress, and succeeded by an ill-conditioned discharge, which con- 
cretes into thin and superficial scabs, that are easily rubbed off and 
presently regenerated." 2 



1 Dublin Journal, August, 1849, p. 45. 

2 On Cutaneous Diseases, p. 243. 



RUPIA. 575 

We are only concerned with one of his three varieties, however, the 
rupia escharotica, which appears to be identical with the disease de- 
scribed by Dr. Whitley Stokes, and others, under the name of pemphi- 
gus gangrenosum. Dr. Bateman says that " it affects only infants and 
young children when in a cachectic state, whether induced by previous 
diseases, especially the smallpox, or by imperfect feeding and clothing, 
&G. ; whence, among the poor, where it is commonly seen, it often ter- 
minates fatally. The vesicles generally occur on the loins, thighs, and 
lower extremities, and appear to contain a corrosive sanies ; many of 
them terminate with gangrenous eschars, which leave deep pits." 1 

It is not stated by writers in general to be either a very frequent or 
fatal affection ; yet in Ireland it appears to be both in a very high de- 
gree, for I find in Dr. Wilde's Report that in ten years the mortality 
amounted to 17,779, in the proportion of 100 males to 78.93 females. 
The country people give it the significant names of "white blister," "eat- 
ing or mortifying hive," "burnt holes," and among them it appears to 
prevail as an epidemic occasionally. Dr. Whitley Stokes, who published a 
valuable paper upon this subject in 1808, states that " the causes of 
this malady are rather obscure, it seems exclusively confined to children. 
Dr. Spear observed that it was confined to children of three months and 
from that to five years, but it has been observed, near Dublin, in chil- 
dren of nine years old. It attacks the finest children in preference: the 
children of the poor more frequently than those of the affluent : those 
who live in damp situations seem more particularly subject to it than 
others. It appears to be infectious, though obscurely so in general, but 
in the year 1800 Dr. Spear observed it to spread epidemically." Bub. 
Med. | Phys. Essays, vol. i. 1808. 

MM. Cazenave and Shedel describe it as commencing with livid spots, 
slightly prominent, upon which the epidermis is soon elevated by the 
effusion of serum until they form large bullae, flat, and of irregular form, 
surrounded by a livid circle. These vesicles break, and expose irregu- 
lar ulcerations, varying in depth and extent, with red border and un- 
healthy surface. There is severe pain, much fever, sleeplessness, and, 
when the disease is extensive, death may occur in a week or two. 

In one or two cases which came under my care I was informed that 
the disease commenced by a vesicle filled with clear serum, which 
enlarged speedily, and the serum became opaque. The borders were 
slightly red. When I saw the case, the bullae had burst and exposed an 
irregular ulceration with defined edges slightly inflamed, and with a 
tolerably healthy surface. 

818. Treatment. — It will be necessary to attempt to improve the 
general condition of the child, if we hope to cure the local disease. 
Cleanliness, comfortable clothing, pure air, and good diet, must be 
afforded. If there be much fever, of course the diet must be moderate 
but nourishing, and by degrees broth, beef-tea, or solid animal food, may 
be given. 

The local applications will consist, in the first instance, of caustics — ■ 
the nitrate of silver, the acid nitrate of mercury, dilute nitric or muri- 

1 On Cutaneous Diseases, p, 244, 



576 IMPETIGO. 

atic acid, &c. — so as to change the surface and arrest the ulceration, 
after which poultices may be applied. 

M. Biett has succeeded with the proto-ioduret and deuto-ioduret of 
mercury in the form of ointment ; a scruple of the former, and from 
twelve to fifteen grains of the latter, to an ounce of lard. 



CHAPTER III. 

IMPETIGO. — PORRIGO. 
I. IMPETIGO. 



819. We now come to the consideration of pustular eruptions, and 
the one I shall first notice is one which occasionally assumes a vesicular 
appearance, although really pustular. Impetigo, moist or running 
tetter, is marked by small psydracious pustules, neither accompanied by 
fever, nor contagious, nor communicable by' inoculation. Dr. Bateman 
says that it chiefly occurs on the extremities, but it may also attack the 
head. In children it is very apt to appear in parts where there is much 
movement, such as the flexures of large joints, and is accompanied with 
intense itching. It may be excited by dentition, disorder of the stomach 
and bowels, &c, and is frequent in children of deteriorated constitutions. 

When it attacks the scalp it is preceded for a few days by feverish 
symptoms, and sometimes by vomiting ; the scalp is hot and tender, and 
with a slight redness where the eruption is about to appear. The pus- 
tules are psydracious, occurring singly or in groups, with inflamed bases. 
Each pustule contains thick, yellow, purulent matter, which is soon 
matured, and forms a greenish-yellow scab. This form Dr. Neligan 
considers to assume a chronic form but rarely; fresh pustules appearing 
in different parts of the scalp as the old ones heal. 

820. " The second form of the disease is characterized by the erup- 
tion occurring in groups of pustules, but the individual pustules are also 
different in character, being of the variety which have been termed 
achores. Their appearance is attended with more decided symptoms of 
inflammation, both general and local, and the heat and itching are in 
many cases so severe that children tear the scalp, and prevent the dis- 
ease from presenting the truly pustular character of the first stage. The 
eruption usually commences on the forehead, involving at the same 
time some of the hairy scalp. The inflamed patches vary in size and 
form in different cases; in some extending in their longest measurement 
not more than from half an inch to one or two inches, while in others 
the greater part of the scalp is involved from the very commencement. 
In nearly every instance the skin bordering on the scalp is more or less 
engaged in the disease, and it often appears at the same time in the 
ears or on some part of the face. The pustules are not so large as when 
they occur singly; their coats are apparently thinner, and the pus which 



IMPETIGO. 577 

they contain is not so consistent, and is of a richer yellow color. They 
usually become confluent before they burst, and the resulting greenish- 
yellow (when chronic, greenish-brown) scab is consequently much more 
extensive. When the eruption has continued for any length of time, 
large quantities of bright yellow pus are secreted beneath the greenish 
crusts, which separate in cracks, to give exit to the matter, exhibiting 
beneath the highly inflamed raw surface of the scalp, from which the 
pus is secreted." 1 

The disease does not appear to be contagious ; it chiefly occurs in 
infancy and childhood, and may last for years, if neglected. It con- 
stitutes the crusta lactea of authors. 

I cannot agree with Dr. Neligan that the hair is unaltered; it is not 
so rapidly or so completely destroyed as by porrigo, but, if the disease 
be of long standing, the roots of the hair are injured, and its growth 
checked ; it becomes thin and poor-looking. 

In this, as in other severe eruptions of the scalp, the glands at the 
sides and back of the neck, below the hair, are apt to be enlarged and 
tender, but they rarely suppurate. Small abscesses sometimes form 
at the nape of the neck, close to the roots of the hair. 

I have no doubt that occasionally a brisk eruption on the head may 
prove a salutary counter-irritation, and hence I suppose has arisen the 
popular objection to curing them. But I do not conceive that there is 
any danger if due care be taken, and I am quite sure that many evils 
follow their long continuance. Sore eyes or ears, otorrhoea, glandular 
swellings, &c. may, I believe, often trace their origin to a chronic erup- 
tion neglected. 

821. Treatment. — From the amount of inflammation present, our 
first applications must be of a soothing character. After cutting the 
hair as short as possible with a pair of scissors, a poultice of bread and 
milk, or linseed meal, may be applied over the inflamed parts, or they 
may be frequently fomented with the decoction of poppy-heads. At 
the same time, if the child can well bear it, a brisk purgative should be 
given, and the child put upon low diet, or confined to milk, as Dr. 
Neligan recommends. With children who are in bad health, or whose 
constitution has been impaired, we must use caution as to purgatives, 
and it may be desirable to allow a more generous diet. 

When the redness is diminished, and the irritation is calmed, we may 
use a lotion of the sugar of lead, black wash, or the alkaline lotion 
recently described, with the alkaline ointment. 

This treatment, with cleanliness and pure air, will soon effect a 
change in the aspect of the disease, unless the child be teething, and 
then, although dentition did not cause the disease, it may be kept up 
for some time, until the teeth are cut. Even lancing the gums, which 
should always be done, will not always immediately relieve the irritation. 

1 Dublin Journal, August, 1848, p. 39, 



37 



578 PORRIGO. 



IT. PORRIGO, OR SCALD HEAD. 

By Bateman and the older writers, porrigo has been regarded as a 
pustular disease, the result of inflammation. Comparatively recent 
researches with the microscope, however, seem to have established the 
fact of two varieties, at least, being of vegetable origin, and not the 
result of inflammation. We are indebted to the investigations of Schon- 
lein, Gruby, Bennett, Corrigan, Miiller, Lebert, Robin, &c, for the 
amount of our present knowledge. But it follows, if this view be the 
true one, that some of the varieties usually included under porrigo must 
either be made a separate order, or included among the impetiginous 
eruptions, leaving the porrigo scutulata and porrigo favosa (or perhaps 
the p. favosa alone) as an order of vegetable productions of the scalp, 
the result of constitutional causes chiefly, and not of inflammation. 

Dr. Bateman describes six varieties, the -porrigo larvalis, or crusta 
lactea, the porrigo purpurans, the porrigo deealvans, the porrigo lupi- 
nosa, the porrigo scutulata, or ringworm of the scalp, and the porrigo 
favosa. They differ in the size of the pustules, and the form of the 
crusts or scabs. 

822. The porrigo larvalis u commonly appears first on the forehead 
and cheeks, in an eruption of numerous minute and whitish achores, 
which are crowded together oh a red surface. These pustules soon 
break, and discharge a viscid fluid, which concretes into thin yellowish 
or greenish scabs. As the pustular patches spread, the discharge is 
renewed, and continues also from beneath the scabs, increasing their 
thickness and extent, until the forehead, cheeks, and even the whole 
face become enveloped as by a mask (whence the epithet larvalis), the 
eyelids and nose alone remaining exempt from the incrustation. The 
eruption is liable, however, t'o considerable variation in its course, the 
discharge being sometimes profuse, and the surface red and excoriated, 
and at other times scarcely perceptible, so that the surface remains 
covered with a dry and brown scab. When the scab ultimately falls 
off, and ceases to be renewed, a red, elevated, and tender cuticle, 
marked with deep lines, and exfoliating, is left behind." Other parts 
of the body may be attacked, and the irritation occasions loss of sleep, 
and much distress to young infants. The description I have quoted 
from Bateman resembles that of impetigo, already given by Br. Neli- 
gan, and it would often be difficult to decide whether the eruption was 
impetigo or porrigo larvalis, unless we confine the genus porrigo to the 
porrigo scutulata and favosa. The treatment recommended for impetigo 
is well suited to the present species. 



THE PORRIGO SCUTULATA, OR RINGWORM OF THE SCALP, 

823. Has given rise to great difference of opinion as to whether it is 
a pustular or vesicular disease, and whether the pustules or vesicles are 
at all essential to the disease. Willan, Bateman, Biett, and the older 
writers, class it among the former ; some of the French writers, espe- 



PORRIGO. 579 

cially M. Cazenave, among the vesicular. Dr. Neligan considers herpes 
to be the true ringworm ; and Dr. Burgess 1 regards this form as the 
result of abnormal irritation of the bulbs of the hair. When such emi- 
nent dermatologists differ, I cannot expect to be able to decide. I can 
scarcely doubt, after the examination I have made, that there is a form 
of ringworm, the element of which is a vesicle, but this does not prove 
that a pustular eruption may not assume this character. Dr. Burgess's 
description differs equally from that given by Bateman and that by 
Neligan. Dr. Bateman states that "it commences with clusters of small 
light yellow pustules, which soon break and form those scabs over each 
patch, which, if neglected, become thick and hard by accumulation. If 
the scabs are removed, however, the surface of the patches is left red 
and shining, but studded with slight elevated points or papulse, on some 
of which minute globules of pus again appear in a few days. By these 
repetitions of the eruptions of achores, the incrustations become thicker, 
and the areas of the patches extend, often becoming confluent, if the 
progress of the disease be unimpeded, so as to affect the whole head. 
As the patches extend, the hair covering them becomes lighter in its 
color, and sometimes breaks off short ; and as the process of pustula- 
tion and scabbing is repeated, the roots of the hair are destroyed, and 
at length there remains uninjured only a narrow border of hair round 
the head." 2 

Dr. Burgess, one of the most recent writers on the subject, thus de- 
scribes the disease: "We have seldom an opportunity of seeing ring- 
worm in the early stage, for the patient, even, is not aware of its 
presence for some time after its development, and the first indication is 
a trifling degree of itching in the parts, which is relieved by the dis- 
lodgement of a thin scruff' in the act of scratching. It is this circum- 
stance which first directs attention to the disease. If examined now, 
there will be found neither heat, redness, nor moisture on the morbid 
surface, but a thin layer of furfuraceous matter, of an oval or circular 
form surrounding the hair, either singly or in small groups. These cir- 
cular patches are always few in number and limited in extent ; fre- 
quently there is only a single diseased spot to be found on the head, 
which, if observed early, will be found to extend from a small point or 
nucleus by its periphery, until the spot attains a certain size of limited 
circumference, when it ceases to extend, and within these limits the dis- 
ease passes through its various phases. The skin is dry, uneven, and 
covered with rough eminences, insensible to the eye and to the touch, 
which give it the appearance of the prickly condition of skin called 
'cutis anserina.' These mammillary projections are enlarged and dis- 
eased hair follicles, propelled by the hair in its growth from beneath 
the level of the skin; and if we endeavor to pull the hair, it will not be 
detached from the root, but break on a level with, or a short distance 
from, the mouth of the follicle. The hair that grows on the morbid 
surface, after it has arrived at the condition described, does not attain 
any length, but breaks spontaneously at a short distance from the skin, 

1 Eruptions of the Face, Head, and Hands, p. 176. 

2 Oa Cutaneous Diseases, p. 169. 



580 POKRIGO. 

leaving an exposed patch of the scalp, which always maintains a circu- 
lar, disk-like form. The ends of the broken hairs are jagged, disco- 
lored, twisted, and not unlike the filaments of flax and tow. If the 
disease has not been arrested at this stage, the furfuraceous, scaly mat- 
ter will become agglomerated, and form dry, thick, dirty, yellow-looking 
scabs or incrustations, thicker at their circumference than towards the 
centre. It is the irritation produced by these scabs, but more particu- 
larly by the action of the nails in scratching or trying to dislodge them, 
that produces the pustules, and subsequently the discharge of the con- 
tents around the original disease, which deceived Willan, and induced 
him to place ringworm amongst the pustular eruptions of the scalp. He 
mistook an incidental or superinduced lesion for the element of the dis- 
ease, which is totally different." 1 

Whether Dr. Burgess is right in considering these pustules as acci- 
dental, produced by the cause he mentions, may be doubted, I think; 
nor is this inconsistent with his view of the nature of the disease, which 
he regards as "the result of a vitiated or abnormal nutrition in the 
organs which secrete the hair, analogous to scrofulous degenerations 
which occur in other structures of the body. The seat of the disease is 
not in the hair but in the organs which secrete it ; and the vegetable 
productions so minutely described by Gruby, of the existence of which 
there can be no doubt, is a secondary product, and not the disease itself." 

Let us now see what has been observed of this "vegetable para- 
site." M. Gruby remarks : " On examining attentively with the micro- 
scope this grayish-white powder which is seen on the morbid surface, 
you will be surprised to find that it is composed of a number of crypto- 
gamia. On submitting the hairs which grow on this surface to the same 
method of examination, we shall observe a great quantity of these cryp- 
togames embracing the cylinder of the hair on all sides, and forming 
round it a perfect vegetable sheath, which accompanies the hair for a 
short distance after its exit from the follicles. The structure of the 
hair becomes less transparent ; the fibrous portion is interspersed with 
extremely minute granular molecules, which separate the fibres from 
each other in part or wholly, the size of which is estimated at the five- 
thousandth part of an inch in diameter, and the shaft of the hair is dis- 
tinctly enlarged or hypertrophied. The cryptogame surrounding the 
hairs at their bases, by contact with the adjoining hairs, involves them 
in the same morbid condition, altering the texture gradually, until they 
break off short, and thus expose a circular patch of partial baldness. 
These vegetable parasites are produced with surprising rapidity. On 
issuing from the follicle, the hairs become grayish for a certain distance, 
and in eight days break at the line where the cryptogame surrounds 
them. The hairs which are most enlarged resist for a longer period, 
and, according as they rise above the level of the skin, are attacked by 
the parasitic fungus. They are often surrounded at their base by a 
quantity of cryptogamia sufficient to form a small, grayish elevation. 
It is these accumulations which have been mistaken for pustules, vesi- 
cles, and the secretion of the sebaceous follicles." 

1 Eruptions of the Head, Face, and Hands, p. 177. 



PORRIGO. 581 

According to M. Robin, 1 the seat of this vegetable (trichophyton ton- 
surans) is in the interior of the roots of the hair, and he has described 
another (microsperon audonini) which is seated round the roots of the 
hair like a cylinder. 

In the midst of such varying opinions, all that seems agreed upon as 
to the disease is, the presence of circular or oval spots of, at first, a 
furfuraceous secretion, upon which ultimately something like pustules, 
at least, appears ; that the hair is at first injured, and then falls ; that 
in all probability the disease involves the follicle ; and that the secre- 
tion is of the nature of a vegetable parasite. 

The disease is also highly contagious, and, according to Gruby, it is 
transmitted by means of the furfuraceous powder, or cryptogame. 
Approximation of the head, or wearing the same cap, hat, or bonnet, 
will communicate the disease to another person hitherto free. I have 
seen spots of ringworm produced on different exposed parts of the body 
of a person employed in dressing the head of a child in whom this scurf 
was very profuse, which so far confirms M. Gruby's opinion. 

This affection is sufficiently common in children from three years old, 
and often proves very obstinate, lasting several years. Those of a 
feeble and flabby habit, the ill-fed, ill-clothed, and uncleanly, who live 
in unwholesome habitations, are the most exposed to it ; but it may be 
communicated to those in health and of good constitutions. 

824. Treatment. — So long as the spots exhibit much redness, our ap- 
plications must be adapted to soothe; poultices, emollient fomentations, 
&c. will be most suitable. The hair must be clipped as short as pos- 
sible, which is much better than shaving, though more tedious, and 
requiring more frequent repetition. 

When the inflammation is subdued, or the disease has become chronic, 
we may proceed with more direct attempts to act upon the diseased 
portion. "In the more irritative states, the milder ointments, such as 
those prepared with the cocculus Indicus, with the submuriate of mer- 
cury, the oxide of zinc, the superacetate of lead, or with opium or 
tobacco, should be employed; or sedative lotions, such as decoctions or 
infusions of poppy-heads, or of tobacco may be substituted. When there 
is an acrimonious discharge, the zinc and saturnine lotions, with the 
milder mercurial ones, such as the ung. hyd. praacip. albi, or the oint- 
ment of calomel, or a lotion of lime-water with calomel, are advantage- 
ous. According to the different degrees of inertness which ensue, 
various well-known stimulants must be resorted to, and may be diluted 
or strengthened, or combined, according to the circumstances. The 
mercurial ointments, as the ung. hyd. pnecip., ung. hyd. nitrico-oxydi, 
and especially of the hyd. nitrat., are often effectual remedies ; and 
those prepared with sulphur, tar, hellebore, and turpentine, the ung. 
elerni, &c, separately or in combination, occasionally succeed, as well 
as preparations of mustard, black pepper, capsicum, galls, rue, and 
other acrid vegetable substances. Lotions containing the sulphates of 
zinc and copper, or the oxymuriate of mercury in solution, are likewise 
occasionally beneficial." 2 

1 Des Vegetaux qui croissent sur l'Homme, &c. 

2 Bateman on Cutaneous Diseases, p. 172. 



582 PGRRIGO. 

M. Biett was in the habit of using the sulphuret of potash, the iodide 
of sulphur, or solutions of the sulphate of copper, zinc, nitrate of silver, 
corrosive sublimate, &c, with success. 

M. Cazenave recommends an ointment of one part of pitch to two of 
citrine ointment, and another with a scruple of tannin to an ounce of 
lard, as the most effectual ointments in this disease. 

Dr. Burgess speaks highly of a "lotion of the bicyanuret of mercury, 
in the proportion of one or two grains to the ounce, according to the 
amount of stimulus required, which will be found more serviceable than 
these, or even the solution of the bichloride of mercury, so commonly 
used in this eruption and in favus." If the latter be used, lint soaked 
in it should be applied to the parts, and covered with thin gutta-percha 
or oil-skin ; but the former is to be laid on with a camel's-hair pencil. 
" The local remedy, however, which I have found most effectual in the 
treatment of this obstinate complaint is the vapor of iodine and sulphur, 
conveyed directly to the morbid patch through a caoutchouc tube, from 
any simple apparatus for igniting the compound, the patient lying in 
the horizontal position during the application of the vapor. It will 
stimulate the parts greatly if applied for twenty minutes, and the dis- 
eased surface, which was previously dry and pale, will appear slightly 
red arid bedewed with moisture. The following formula will be strong 
enough to commence with, which may be afterwards increased according 
to circumstances : — 

R.— Sulphur sjiij. 

Iodiui, gr. xij to gr. xxiv. 
To be divided into sis powders — one to be applied three times a day." 1 

M. Bazin first removed the hair by an ointment of lime and carbon- 
ate of soda, of each one part, lard thirty parts ; and then a solution of 
bichloride of mercury (1 part to 250 of water), or an ointment of the 
acetate of copper. 

Dr. Parker has recommended a solution of pernitrate of mercury (1 
part to 30 or 40 of water), or an ointment of sulphate of copper (1 part), 
alum (3 parts), and lard (20 or 30 parts). 2 Dr. Jenner has successfully 
employed sulphurous acid. 3 

The local applications I have found most useful, after the redness 
had subsided, are the black wash, diluted citrine ointment, ointment of 
the acetate of lead or oxide of zinc, or hydriodate of potass, and when 
chronic and obstinate, nitrate of silver or tincture of iodine — the latter 
particularly. The patches should be painted with it every second or 
third day. 

825. But local treatment will not be sufficient; we must carefully 
remove any irritation, such as that from dentition or disordered bowels, 
and regulate the state of the stomach and bowels; after which in badly 
nourished, lymphatic, or scrofulous children we must endeavor to raise 
the tone of the system by good diet and tonics, either mineral or vege- 

, ' Eruptions of the Head, Face, and Hands, p. 182. 

2 Brit, and For. Med. Rev., Oct. 1853, p. 418. 

3 Med. Times and Gazette, Aug. 1853. 



POKRIGO. 583 

table, or the mineral acids. Dr. Burgess recommends the citrate of 
iron in infusion of quassia, or a bitter infusion -with the hydriodate of 
potass. 

Much time is generally required, and great care before this obstinate 
disease is cured, and if the treatment be suspended too soon, before the 
surface of the patches is smooth, pale, and free from scurf, a relapse is 
almost sure to take place. I think that when the disease has been so 
far subdued that nothing marks its having existed but the bald spots 
and a slight excess of furfuraceous scales, I have derived much benefit 
from a weak ointment of hydriodate of potass; and at this stage oint- 
ments seem more useful than lotions. 

The hair must be kept quite short until some time after the disease 
is cured, and when there is no longer danger of much irritation, it may 
be well to have the entire head shaved once or twice ; it strengthens the 
growth of the hair on the bald spots, and secures an even length over 
the head. When it is allowed to grow, a little very thin oil of almonds 
may be used occasionally ; the common hair-oils are far too thick, and 
only neutralize all efforts at cleanliness. 

The head should be washed occasionally, but nothing can be more 
injurious both to the tender scalp and hair than the liberal use of soap. 
By far the best substitute is a portion of the yolk of an egg ; if it be 
well washed off with fresh water, it leaves the scalp perfectly clean 
and pale, and the hair soft and silky. 



PORRIGO FAVOSA. 

826. Notwithstanding the opinions of Willan, Bateman, Alibert, Biett, 
and others, of the pustular character of porrigo favosa, it seems clearly 
established now that this variety at least is of vegetable nature. It is 
true that Dr. Mahon considers it a morbid secretion of the sebaceous 
glands, and Drs. Bennett and Burgess and M. Erichsen as a tubercular 
disease; but the researches of Schonlein, Gruby, Remak, Corrigan, 
Robin, &c, seem to have pretty well set the question at rest. 

The confusion as to the nature of the disease may have partly arisen, 
as Dr. Corrigan suggests, from the presence of two species of eruption 
on the scalp at the same time. He considers the disease as essentially 
pustular, but that the growth upon the skin is a vegetable parasite, and 
he describes the growth from the beginning. If the scalp be shaved 
and the scabs removed, we may soon observe the whole process of repro- 
duction. "Within some days, a few, often not more than three or four, 
very minute pustules will show themselves, scattered far asunder over 
the red surface ; they are not raised above the surface, and they seem 
like dots of transparent amber-colored matter bedded in the skin. In 
twenty-four hours after, they become solid, depressed in the centre, and 
of a pale yellow color, very often with a hair in the centre of each. 
They then rapidly increase in number and size." 1 These crusts consti- 
tute the vegetable parasite, underneath which the skin is red but un- 

1 Dublin Hosp. Gazette, Aug. 15, 1846, p. 2. 



584 porrigo. 

broken, and not secreting matter. Dr. Corrigan has established the 
fact that the appearance of the matter under the microscope is distinct- 
ive of this variety. 

In the first stage, it neither gives rise to heat of the scalp nor itch- 
ing; it commences generally at the edge of the scalp, and from thence 
spreads rapidly over the head, very often occupying nearly the entire 
surface of the scalp. The eruption is occasionally, but more rarely, 
seen on different parts of the body. 

"The appearance of this eruption is so peculiar and so distinct from 
all the other eruptive diseases of the scalp that it cannot possibly be 
mistaken for any of them. It first appears in the form of small, yellow, 
dry spots, about the size of a pin's head, of a bright yellow color, seated 
on the surface of the skin, which is depressed slightly by them ; each 
spot is distinct, hemispherical, slightly concave or cup-shaped on its 
free surface, and convex beneath, where it is adherent to the skin. On 
removing the small diseased mass, that portion of the scalp on which it 
was seated is found to be somewhat depressed, smooth, and shining. A 
single crust of the disease, or favus, as it has been termed from its 
honeycomb appearance, is often traversed by one or sometimes by two 
hairs, which appear to grow as it were from its very centre or most 
depressed portion. This has given rise to the notion that the disease is 
one of the bulbs of the hair ; but the fact of its appearance on other 
parts of the body which are quite free from hair is a sufficient refutation 
of this opinion. The eruption spreads by additions to the outer edge or 
circumference of each crust, which thus retains its hemispherical cha- 
racter, until it attains a diameter of two or three lines, or sometimes 
more. In a case which I have had recently under my care in hospital, 
some of the favi which were seated on the back of the trunk were fully 
half an inch in diameter; on the head, however, they rarely exceed the 
size above mentioned. The adjacent favi, as they increase, unite with 
each other, and form large irregularly shaped masses, in which the 
original circular form of the individual crust is lost; the centre also of 
each is changed in appearance, and, instead of the cup-shaped depres- 
sion, the entire surface is covered with alternate elevations and depres- 
sions, or, so to speak, ridges and furrows, concentrically arranged. The 
eruption thus increasing, the whole of the scalp — often, too, the fore- 
head, neck, and parts of the trunk — become encased in one large yellow 
crust, at the edges of which some favi, of the peculiar characteristic 
appearance, are invariably to be seen. The crusts of porrigo are of a 
pale sulphur-yellow color; they are hard and dry, and break with short 
fracture, exhibiting within a mealy powder, of a paler yellow than the 
external surface. They may generally be removed with facility from 
the scalp ; but they bring away with them a thin layer of epidermis, 
which is firmly adherent to their under surface, through which small 
projections may be seen with a moderate lens, sometimes with the naked 
eye. These projections or processes pass into the dermis beneath, and 
when the crusts are torn forcibly away, blood issues through the small 
orifices into which they were inserted. From the very commencement 
of the eruption of porrigo the hair becomes altered ; much of it falls 
out, and the straggling hairs that remain are thin, broken, weak, whitish. 



PORRIGO. 585 

and readily removable with the crusts of the disease, in which they are 
firmly imbedded. When this affection has continued for any length of 
time, bald patches are left after cure, on which the hair does not again 
grow ; and even when it has been cured at an earlier stage, the hair 
never regains its proper character, being weak, thin, and of a pale, 
whitish-yellow color. As the disease advances, much irritation of the 
scalp is produced ; small pustules form here and there in spots as yet 
unaffected with the eruption ; the tingling and heat are so unbearable 
as to compel the patient to tear the surface with his nails, even to such 
a degree as to cause ulceration ; innumerable pediculi are engendered ; 
the favous crusts emit an abominable odor, resembling that of urine ; 
and a copious offensive discharge is secreted by the pustules and ulcer- 
ated spots — in short, an individual affected with this disease in its 
aggravated form becomes a loathsome and disgusting object." 1 

In some parts of the inflamed surface, ulceration occurs, spreading 
irregularly, and becoming very troublesome. 

The great irritation of the scalp is extended along the lymphatics, 
and the glands around the neck become enlarged and tender ; they 
sometimes, but rarely, suppurate. 

M. Biett observes that it is rare that any internal organ becomes 
inflamed. 

827. With regard to the character and appearance of this vegetable 
favus, Dr. Neligan gives the following extract from M. Robin: "Re- 
duced to powder and placed under the microscope, it presents a mix- 
ture, 1, Of tortuous, branching tubes, without partitions, empty, or 
containing a few molecular granules {mycelium); 2, Straight or crooked, 
but not tortuous tubes, sometimes, but rarely, branched, containing gra- 
nules, or small rounded cellules, or elongated cellules, placed end to 
end, so as to represent partitioned tubes, with or without jointed articu- 
lations [receptacles or sporangia in various states of development ?); 
3, Finally, sporules, free, or united into bead-like strings. The myce- 
lium is very abundant near the inner surface of the external layer, to 
which it adheres. The spongy, friable mass of the centre of each favus 
is principally formed of the sporules and the different tubes containing 
mycelium already described {sporangia or receptacles ?). We often find 
mixed with them mycelium tubes, but in small quantity. All these ele- 
ments pass insensibly into each other; empty tubes {myceliuiii); tubes 
containing small round corpuscles ; tubes with corpuscles as large as 
the smaller sporules ; sporules placed end to end so as to resemble a 
hollow partitioned cylinder, with a tendency to separate at the joints ; 
and free sporules. Bennett has given a good drawing of this arrange- 
ment." 2 

828. That porrigo favosa is a contagious disease, we have proof in 
the experience of ages ; and that it can be propagated by inoculation 
has been shown by Remak and Bennett, although Gruby and others 
failed. They failed, as Neligan observes, because, in addition to the 
mycelia by which it is propagated, they wanted the proper soil, i. e. the 

1 Neligan; Dublin Journal, August, 1848, p. 52. 

2 Des Vegetaux qui croissent sur l'Homme et sur les Anhnaux divans, 1847, p. 8. 



586 PORRIGO. 

state of constitution produced by filth, close air, bad feeding, and insuf- 
ficient clothing. 

It is a very rare disease in Ireland, as Dr. Corrigan observes, and 
almost never met with in persons of a respectable station. " Can it be," 
Dr. Corrigan asks, " that, like the cow-pox, it is a disease propagated 
from some inferior animal, perhaps the mouse, on which Dr. Bennett 
has discovered the same parasitic plant as in porrigo ? while the disease 
in the human subject, as if to strengthen the supposition, gives out so 
strongly the odor of the mouse, that it forms a well-marked diagnostic 
sign of the disease ? and that to favor its production, poverty or sickli- 
ness must have reduced the living body to a state fit to constitute a 
nidus for a parasitic plant ; as in parasitic growths, the more feeble or 
more sickly the animal is, the more will such growths develop them- 
selves." 

829. Treatment. — Our first object is the removal of the crusts and 
the diminution of the inflammation, and this will be best attained by the 
application of poultices for twenty-four hours, which should be changed 
as often as they become dry. The hair should be cut as close as pos- 
sible previously, but not shaved at this period. 

Dr. Bateman recommends the application of the ung. zinci, or the 
ung. hydr. prsecip. albi, mixed with the former, or with a saturnine 
ointment, or "the ointment of the nitrate of mercury, diluted with about 
equal parts of simple cerate, and of the ceratum plumbi superacetatis," 
varying the proportions of the ung. cerge according to the degree of 
inflammation. 

M. Biett speaks most favorably of alkaline or sulphurous applications, 
or acid lotions. The subcarbonate of soda or potash, in form of oint- 
ment at first, and afterwards more diluted as a lotion ; or the following 
lotion, which is much used at St. Louis : — 

R. — Potass, sulphuret. gij. 
Sapon. alb. gijss. 
Alcohol, rect. 3J. 
Aquse calcis, gvij. — M. 

Muriatic or nitric acid much diluted, sulphurous douches; or, if more 
powerful applications are needed, solutions of sulphate of zinc or cop- 
per, nitrate of silver, or corrosive sublimate, may be tried. 

M. Biett has also found benefit from the use of the iodide of sulphur, 
applied by gentle friction in the form of an ointment, containing from a 
scruple to half a drachm, to an ounce of lard. 1 

Dr. Corrigan speaks highly of the oxymuriate of mercury, which he 
employed because of its power of destroying the sporules of cryptogamic 
plants. " I have used it," he says, "in the form of ointment in the 
proportion of five grains in very fine powder to an ounce of ung. cetacei. 
I have used it in the proportion of ten grains to the ounce, but it some- 
times gives pain in this large proportion. A small portion of the oint- 
ment is rubbed in on the part affected every day. It has not salivated 
in any instance in which I have employed it ; its action in the first of 
these cases was peculiarly satisfactory," &c. 

1 Cazenave and Shedel, Mai. de la Peau, p. 244. 



PORRIGO. 587 

M. Mahon lias a depilatory which removes the hairs very completely. 
M. Chevalier believes it to be chiefly composed of lime and carbonate of 
potash. The carbonate of potash, the lotion recommended by Biett and 
Neligan, of which I have already spoken, will answer this purpose very 
well. 

Dr. Neligan's method is as follows : " As soon as the poultice is re- 
moved, the head is well washed with the stronger carbonate of potash 
lotion, and slightly brushed with a soft hair-brush, or a roll of lint ; the 
scalp is then covered with the carbonate of potash ointment, spread on 
lint, and over it a closely fitting oil-silk cap is placed ; the ointment is 
renewed twice daily. By the use of these applications the crusts of the 
eruption are generally completely removed in from two to three days. 
The carbonate of potash ointment is at the expiration of this time 
replaced by one containing the iodide of lead, in the proportion of half 
a drachm of the iodide to an ounce of prepared lard ; the head is to be 
still washed every morning with the carbonate of potash lotion. In some 
cases it will be found that the iodide of lead ointment excites a certain 
degree of inflammation of the surface of the scalp after it has been used 
for some days ; when such occurs, it should not be applied for a day or 
two, and the lotion alone employed three or four times daily. After 
this first attack of inflammation disappears, I have not seen it again 
recur, although the use of the ointment had been persisted in for months. 
The strength of this ointment should be increased after a fortnight, if 
the disease again appears, even to double that above indicated." 

After this treatment or any other has been continued for some time, 
it should be suspended for a time, to see if the disease will recur, or if 
it be really cured. If it reappear we must again have recourse to the 
external applications, as well as to the internal remedies. 

Professor Hebra, of Vienna, directs his attention first to the destruc- 
tion of the plant, and then to the prevention of its reproduction: "With 
this view he orders the hair to be cut close, and, after the favous crusts 
are softened by a sufficient quantity of oil, the head should be enveloped 
in warm fomentations, composed of a melange of soap and bran, which 
are to be continued until the incrustations covering the scalp begin to 
swell, and detach themselves from their bases. After removing these 
softened crusts with a spatula, the brush and comb should be used, and 
the scalp examined carefully (which will be found very red, bleeding 
easily, and the seat of several excoriations), so as to ascertain if there 
is still any favous matter remaining; for it is necessary to remove the 
seeds of the disease from the epidermic cells and hair follicles, in order 
to prevent their reproduction. To attain both these objects, M. Hebra 
strongly recommends lotions of the deuto-chloruret of mercury, of the 
nitrate of silver, or of arsenic, and the ointment of the iodide of lead, 
as very efficacious remedies. He also sometimes employs ointments of 
the cocculus indicus, of quicklime, of the carbonate of potash, the citrine 
ointment, and the dilute mineral acids. He has then succeeded more 
rapidly in completing the cure by the following method than by any 
other: the favous matter being removed from the scalp, the dilute acetic 
acid should be rubbed over the morbid parts until they bleed slightly ; 
when this occurs, the acid is to be omitted, and an alcoholic solution of 



588 PORRIGO. 

iodine applied in its stead, and continued for several weeks, until the 
parasite ceases to be produced." 1 

Dr. Burgess speaks favourably of alkaline lotions and iodide of sulphur, 
as recommended by M. Biett, but he prefers the vapor of iodine and 
sulphur to all other remedies. 

I have found the nitrate of silver and caustic tincture of iodine very 
useful after the removal of the crusts and hairs. 

830. But external applications alone will not be sufficient. In almost 
all cases the disease is a constitutional one, and must be met by consti- 
tutional remedies. After due care in the removal of all irritation from 
teething, or gastro-intestinal disturbance, and a careful regulation of 
the stomach and bowels, we must afford the child the relief of cleanli- 
ness, pure air, and a more invigorating diet, at the same time avoiding 
crude vegetables and fruits, and all stimulating substances. Milk pud- 
dings, broths, and plain animal food, may be given, according to cir- 
cumstances. Dr. Neligan confines the patient entirely to a milk diet. 

The medicines recommended by Bateman are alterative doses of mer- 
curials, " especially when the biliary secretions are defective, the abdo- 
men tumid, or the mesenteric glands enlarged." Small doses of calomel, 
either alone or with soda, and some testaceous powder, or, if the bowels 
are irritable, the hyd. c. creta. If the patient be of a squalid habit, or 
the glandular affections severe, bark and chalybeates, or the muriate of 
barytes combined with the former, will be of service. 

Dr. Neligan speaks most highly of the iodide of arsenic, which he 
says may be safely given to the youngest child, " its effects being, of 
course, duly watched." "The dose of this preparation is, for an aclult, 
from one-tenth to one-fourth of a grain, very gradually increased ; for 
a child six years old, one-fifteenth of a grain ; and for a younger child, 
from one-eighteenth to one-twentieth of a grain. It is best given to 
adults in the form of a pill, made with dry manna and a little mucilage ; 
to a child it is best administered in the form of powder, its minute 
division being perfected by means of a little white sugar or aromatic 
powder. When the system is saturated with this medicine, we usually 
find that some constitutional symptoms, such as acute headache, dryness 
of the throat, &c, are manifested; but, in some cases, I have given it 
in full doses for many weeks without any manifestation of its effects 
further than those produced on the disease for which it was adminis- 
tered. When, however, it gives rise to the symptoms above mentioned, 
its use should be intermitted for some days, and an active purgative 
administered." 2 

When the condition of the child is deteriorated and the nutrition feeble 
much benefit is derived from the use of the cod-liver oil. It will not 
only aid in the cure, but may prevent the evil consequences of a long- 
continued eruption of whatever nature. Dr. Hess has occasionally found 
it act with remarkable benefit. 

1 Burgess on Eruptions of the Face, Head, and Hands, p. 195. 

2 Dublin Journal, August, 1848, p. 56. 



SECTION VI. 



ERUPTIVE FEVERS. 



CHAPTER I. 

MEASLES. — RUBEOLA. — MORBILLI. 

831. Measles consists essentially in an exanthematous eruption of 
the skin and mucous membranes, of a circular or crescentic form on the 
skin, preceded and accompanied by fever, running a defined course, 
occurring epidemically or propagated by infection, and generally attack- 
ing a person but once during a lifetime. 

It is much more common among infants and children than among 
adults, and among the latter than with old people; and, without going 
so deep as some writers have done, the explanation seems to me natural 
and easy. The disease is by no means uncommon; it is often epidemic, 
and always contagious or infectious ; and of course a child takes it the 
first time it is exposed to its influence, which must happen before it is 
many years or perhaps many months old. The reason that fewer adults 
than children take it is simply that the majority of adults had it when 
children. 

Some dispute has arisen as to the antiquity of measles, some authors 
contending that they were known to the ancients ; but Gruner 1 and 
Sprengel have shown that they appeared about the same time as small- 
pox. The earliest account we possess is by Rhazes ; Avicenna has also 
described this disease, and distinguished it from smallpox, with which 
it has been often confounded even in comparatively modern times. 
The distinction was first clearly made by Forestius (1597), Schenck 
(1600), Riverius (1655), and especially by Sydenham (1676), and Hoff- 
mann (1718). 

It has been confounded with scarlatina so recently as in the writings 
of Morton and Watson ; indeed, as Dr. George Burrowes has remarked, 
the distinction between the two diseases was not thoroughly established 
until Dr. Withering's Essay on Scarlet Fever, in 1793, and Dr. Willan's 
Treatise on Cutaneous Diseases, were published. 

832. Some notion of the frequency and fatality of measles may be 
gathered from the fact stated by Dr. Gregory, that, on an average of 
five years, nearly 6 per cent, of the mortality of London is due to mea- 
sles and scarlatina. According to the Fifth Report of the Registrar- 

1 Var. Antiq. ab. Arab, solum repetend., sects 7, 14, 17. 



590 MEASLES. 

General, 81 per cent, of this mortality occurs in children under five 
years old, and 97 per cent, in children under ten years old. 

In his admirable Report upon the Table of Deaths, appended to the 
Census of Ireland taken in 1841, Mr. Wilde states that in the ten years 
preceding, the deaths from measles amount to 30.739, in the proportion 
of 100 males to 96.12 females. " Compared with all diseases ; the deaths 
from this cause amount to 1 in 38.62, and with all the epidemic affections 
to 1 in 12.4, being the sixth most fatal disease of this class. With the 
exception of the year 1840, when 4.491 deaths from this cause are 
returned, measles have presented the most remarkable uniformity 
throughout the entire period. The age at which the disease has proved 
most fatal was from birth to the end of the first year, when the sexes 
were 100 males to 86.74 females ; from the first to the end of the fourth 
year, 100 to 100.04 ; from the fourth to the fifteenth, as 100 to 100.57 ; 
from the fifteenth to the thirtieth, 100 to 138.76 ; and after 30, as 100 
to 161.81." 1 

Now, as we know that a large proportion of those attacked by the 
disease recover, we may infer, from these tables of mortality, the very 
great frequency of measles. 

833. SymjJtoms. — After exposure to the epidemic influence or to 
contagion, an interval elapses before the child exhibits any symptoms 
of the disease. This period of incubation, as it has been termed, may 
vary from a few days to two or three weeks. In the majority of the 
cases inoculated by Dr. Home, the fever showed itself in about the 
seventh day. M. Bouchut, in an epidemic in the Hopital Necker, 
found this period range from twelve to thirty days after exposure. 2 
Dr. Panure, who had opportunities for unusually accurate observations, 
found the period from exposure to contagion to the appearance of the 
eruption to be either thirteen or fourteen days. 3 As a general rule it 
will, I think, be found that the fever commences from the fifth to the 
eighth day. 

The course of the disease, after the fever has set in, may be divided 
into the period of invasion, of eruption, and of decline, and each of these 
may be successively described. 

834. Period of Invasion. — The earliest symptom is a sense of weari- 
ness, and a chilliness increasing to a rigor, and followed by febrile heat 
of skin and quick pulse, increasing in intensity for some hours. Or 
the child may at once awake in the midst of high fever, with dry skin, 
flushed face, a very quick pulse, thirst, &c, in which there is occasion- 
ally some little remission at the appearance of the eruption. The face 
soon becomes flushed, the eyes injected, suffused, sensitive to light, and 
with incessant lachrymation ; the eyelids are swollen, and the child is 
constantly rubbing them and the nose, in consequence of the incessant 
itching and tingling. 

The nasal mucous membrane is red, congested, and so irritable, that 
the contact of air occasions perpetual sneezing. Sometimes epistaxis 

1 Report upon the Tables of Deaths, &c, p. 13. 

2 Mai. des Enfans nouveaux-nes, p. 487. 

3 Mode of Propagation of Measles, by Dr. Panure, of Copenhagen, Edinb. Monthly Jour- 
nal of Medicine, June, 1851, p. 589. 



MEASLES. 591 

occurs, and there is always more or less of a thin, acrid secretion at 
first, which afterwards becomes thicker, and finally muco-puriform. 

The bronchial mucous membrane is equally affected; from the begin- 
ning there is a hoarse, rough cough, dry and laryngeal, and which comes 
on in kinks. It is certainly very characteristic, but I doubt whether 
we could decide upon the nature of the attack by this symptom alone. 
Heberden and Peter Frank met with cases in which the cough did not 
appear till after the eruption. These symptoms do not come on gradu- 
ally, but commonly appear at the very outset of the disease all together. 
Other symptoms occur during this period, but without any regular order. 
M. Heim 1 has noticed a peculiar smell, which he compares to recent 
goose-quills, and which lasts five or six days ; Home compares it to that 
of smallpox ; and Heyfelder thinks that it is stronger in the morning 
than in the evening, and when many patients are together. I have 
certainly noticed a peculiar heavy smell, which appeared to be owing to 
increased cutaneous secretion, but I have not noticed its increase in the 
morning. On the other hand, Guersent, Gondie, Billiet and Barthez 
have not perceived it. 

MM. Blache and Guersent mention that they have frequently ob- 
served a punctated rose color of the vault of the palate to precede the 
eruption of measles, quite distinct from the redness observed in scarla- 
tina, as had been previously remarked by Heim and Marc d'Espine. 2 

Nausea and vomiting occasionally occur during this period ; but, in 
general, the gastro-intestinal mucous membrane seems less affected than 
the pulmonary. The lymphatic glands of the neck, and along the 
margin of the eyelids, are not unfrequently enlarged. 

The urine is generally scanty, of a deep color, very acid, and of in- 
creased density. The urea, chlorides, and sulphates, are frequently 
increased, with a small proportion of albumen. 3 

835. The symptoms I have enumerated are generally present, but 
they may be differently grouped, sometimes the nervous symptoms pre- 
dominate, and we may have delirium, stupor, or convulsions ; in other 
cases, the pulmonary or gastro-intestinal may be more marked, as will 
be shown by great dyspnoea, and frequent cough ; or by vomiting and 
purging. Moreover, if the attack of measles occur in the course of 
another disease, these precursory symptoms will generally be much less 
marked. 

They occupy ordinarily from two to four days; seventy-two hours 
according to Dr. Gregory; but, in some cases, Blache and Guersent 
have known them prolonged for seven, eleven, or even fifteen days. 

Rilliet and Barthez have given the result of their observations in forty 
cases of normal measles: in one case there were no precursory symp- 
toms ; in one, they lasted a few hours; in eight, one day; in eleven, 
two days; in seven, three days; in eight, four days; in two, five days; 
and in two, seven days. 4 

Dr. Panure observed the catarrhal symptoms in the majority of cases 
from two to four days before the eruption, but in sqme they occurred 
four or six days, and in others six or eight days previously. 

1 Hufeland's Journal, 1812. 2 Diet, de M<Sd., vol. xxviii. p. 338. 

3 Ibid. * Mai. des Enfana, vol. ii. p. 681. 



592 MEASLES. 

836. Period of Eruption. — About the third or fourth day we may 
observe a few distinct, elevated, red papulae on the face or forehead, 
resembling flea-bites in size and color, very like those at the commence- 
ment of variola or in typhus fever, but speedily acquiring a very dif- 
ferent appearance. These rapidly increase in number, more profusely 
on the face, but spreading to the chest, body, and extremities, very 
quickly. As the number increases, they coalesce, and, in so doing, 
present their characteristic appearance of irregular semicircles, of a 
red color, or crescents, with clear skin in the centre, or now and then 
a single spot. This appearance, which was first pointed out by Dr. 
Willan, is quite peculiar to measles, and at once distinguishes it from 
scarlatina. 

The surface of the eruption is perceptibly elevated above the sur- 
rounding skin, especially on the face, which is altogether swollen and 
puffy, and less so on the body and limbs. "In many persons." as Dr. 
Willan has remarked, " miliary vesicles appear, during the height of 
the efflorescence, on the neck, breast, and arms ; and papulae often occur 
on the wrists, arms, and fingers." 1 

On the second or third day of the eruption (the sixth of the disease) 
the rash is at its height, after which it begins to subside; at first on the 
face, where it first appeared ; then on the body and limbs ; so that, on 
the ninth da}^ little more than slight discolorations of the skin can be 
detected, and even these disappear by the end of the tenth day from the 
invasion of the disease. 

Until the eruption begins to decline, it is accompanied by intense 
itching occasionally. I have known children kept awake all night by 
it, and so excited that I feared every moment an attack of convulsions. 
In other cases, the itching is more troublesome during the period of 
desquamation. 

837. Unlike some other eruptive fevers, the general symptoms do not 
appear to be relieved when the eruption makes its appearance : in some 
cases the pulse may be a little quieter, but in general it is as quick as 
ever, and the fever as high or higher; the skin is intensely hot, but 
moist ; the tongue loaded with white or yellow fur, interspersed with the 
enlarged, red papillae ; the vault of the palate and the pharynx are red, 
and feel dry and rough; the thirst is great, and the appetite entirely 
lost, until the disease declines; and on the gums around the edges of the 
alveoli, a soft, white pellicle is often deposited, which can easily be 
raised with the finger-nail. 

The catarrh of the mucous membranes continues, the eyes are suffused 
and weeping, the mucus secreted by the conjunctivas is more abundant 
and thicker, and, drying during the night, the eyelids are temporarily 
glued together; the secretion from the nasal mucous membrane is of 
thicker consistence, but not less copious; the cough continues, but is 
a little softer; the voice is still rough and hoarse; there is no diminu- 
tion in the dyspnoea or the bronchitic rales heard in the chest. 

The face is as much swollen as ever, and remains of an intense red 
color until desquamation commences. 

1 Bateman on Cutaneous Diseases, p. 60. 



MEASLES. 593 

The duration of this period varies from three to six or eight days, or 
even longer. M. Reveille-Parise mentions a case in which the eruption 
was as vivid as ever on the tenth day. 1 The disappearance is gradual, 
and follows the same order as their appearance ; they become fainter 
in color and flatter ; the slight red areola around the papulae disappears, 
and the whole acquires a yellowish tinge. 

In those parts where the eruption was most intense, certain yellowish 
spots, stigmata or maculas, remain, and which have been noticed by MM. 
Guersent and Blache, Rayer and Trousseau. They are not very appa- 
rent when the child is quiet, but when excited they assume a deeper 
color ; they seem to be seated in the cutis, and do not disappear under 
pressure ; but whether they are a kind of ecchymosis M. Trousseau will 
not venture to say. They appear connected with a severe form of 
measles. 2 

The general symptoms, and the irritated condition of the mucous 
membranes, simultaneously and gradually diminish. 

838. Period of Desquamation. — About the seventh or eighth day, 
the desquamation of the cutis commences. In some cases this process 
is scarcely marked at all ; in others, it is confined to the face and chest, 
where the eruption has been most severe. Unlike the desquamation in 
scarlatina, in measles we find very small furfuraceous lamellas, which 
appear like fine whitish dust, or in some cases only a cracking of the 
cuticle. The process, when perceptible, lasts for three or four days, 
during which time an equal progress has been made towards health in 
the general symptoms. The pulse has become quiet, the skin cool, the 
tongue cleaner, the thirst less; some little wish is expressed for food ; 
the voice recovers its natural tone ; the cough is softer, and the expec- 
toration free. v 

It not unfrequently happens that at this time diarrhoea sets in, and 
presents all the aspect of a crisis, in which light it is regarded by 
many authorities. After this period, if nothing intervene, the progress 
of the patient to perfect health is rapid and complete. 

839. Thus far I have described only a simple, uncomplicated case of 
measles, which we have seen is marked by preliminary fever and coinci- 
dent irritation of the mucous membranes ; by a semicircular or cres- 
centic eruption of red papula?, with a continuance of the fever and irri- 
tation ; and by the final desquamation of the cuticle, with subsidence of 
the fever, local irritations, and general symptoms : the entire process 
occupying from ten days to a fortnight. Such cases are most favor- 
able, and we may say always recover ; but we have also seen that measles 
is a very fatal disease in children, and it is now our duty to inquire into 
the causes of this fatality, and it will, in almost all cases, be found to 
depend upon some modification of the disease, or upon a defective con- 
stitution in the child, or upon some complication. 

840. Let us then consider — 

I. The Modifications of Measles. — a. The eruption may vary as to 

1 Gazette M^dicale, 1835, vol. iii. p. 360. 

2 Bouchut, Mai. de PEnfance, p. 294. 

38 



594 MEASLES. 

extent ; in some it is abundant and universal ; in others it is limited, 
and consists of but few distinct papulse or rings. 

b. The color may differ much in different cases ; ordinarily it is of 
a vivid or deep red ; in other cases, pale and dirty-looking in sickly 
children ; or it may assume a dark livid color, the rubeola nigra of 
Willan. 

c. The eruption may vary its seat ; it may commence and continue 
most marked, as in a case I lately saw, upon the hands, shoulders, or 
back, or upon the cicatrix of a blister. In the morbillous fever of 
Sydenham (1674), it was principally on the neck and shoulders ; in an 
epidemic at the College de Vendome, in 1826, M. Gendrin observed it 
was confined to the face. In a case mentioned in Rust's journal, the 
eruption occupied one-half of the body only. 1 

d. The eruption is sometimes much more distinct and prominent, and 
this form has been called by the French " rougeole boutanneuse :" these 
papulse become flattened about the third or fourth day. 

e. In some rare cases the spots resemble pupura, being really ecchy- 
moses underneath the cuticle, just as blood may be at the same time 
effused into other organs. The spots are blood-red at first, but gradu- 
ally become yellow as absorption goes on. In other instances they are 
brown, or nearly black : according to Rayer, this hemorrhagic measles 
differs from that variety called by Willan "rubeola nigra." 

None of these variations involve either inconvenience or danger in 
themselves ; the latter may indicate a source of danger in some weak- 
ness or deteriorated condition of the constitution, and may serve to put 
us on our guard against the occurrence of hemorrhage in more im- 
portant organs. 

/. Again, the course of the disease may be anomalous ; the eruption 
may disappear too soon and altogether, or it may return in a day or 
two, accompanied with an increase of fever, and the development of 
symptoms indicating internal disease. " Dr. Willan first noticed this 
circumstance. He records two cases of the kind in his Reports of the 
Diseases of London. Frank, of Vienna, has observed the same thing. 
Dr. Conolly recites a like case, where the renewed eruption was so 
copious and intense on the face as to make it impossible to recognize 
the features. Some years ago, a case in every respect similar occurred 
at Brompton to Dr. Seymour and Mr. Chinnock. Ten days elapsed 
in this instance before the renewal of the exan thematic action." 2 The 
disappearance may be owing to some accidental cause, as cold, irregu- 
larities of diet, &c, or may result from internal organic disease. 

Whenever it occurs, we should never rest until, by repeated and care- 
ful examination, we have assured ourselves of the integrity of every 
organ of the body, or have detected the seat and nature of any internal 
disease. 

Such deviations are not unfrequent when measles occur in the course 
of another disease, or in certain epidemics, or in hospitals for children. 

841. Three other anomalies I must notice: I. The rubeola sine 

1 Bull, de Ferrussac, 1829, vol. xxvi. p. 286. 

2 Dr. Gregory on Eruptive Fevers, p. 104. 



MEASLES. 595 

catarrJio of Dr. Willan, which he observed " in a few rare instances, 
during an epidemic rubeola, which is only important as it leaves the 
susceptibility of receiving the febrile measles after its occurrence. The 
course and appearance of the eruption are the same as in rubeola vul- 
garis, but no catarrh, ophthalmia, or fever accompanies it. An interval 
of many months, even two years, has been observed between this variety 
and the subsequent febrile rubeola; but the latter more frequently takes 
place about three or four days after the non-febrile eruption." 1 

Dr. Gregory says, "that it is a very rare variety, and only interest- 
ing in a pathological point of view." Dr. Hosack witnessed it in New 
York in 1813, and Dr. Dewees mentions that he has had several oppor- 
tunities of seeing it. 

It is, I think, extremely doubtful whether such cases are measles at 
all; they appear to me to belong to the order roseola, of which I spoke 
in the last section ; at all events they possess no distinctive character- 
istics of measles, for the eruption of roseola may present the semi- 
circular or crescentic form. Dr. Gregory remarks that if the prelimi- 
nary fever continue seventy-two hours, the disorder is measles, whether 
catarrh be present or not; but if the eruption succeed a fever of twenty- 
four or forty-eight hours, it is not true measles. 

II. During an epidemic of measles, it has sometimes happened that 
children have been attacked by fever and catarrhal symptoms so closely 
resembling those of measles, that the case has been assumed to be 
measles, although no eruption makes its appearance. Morton mentions 
such a case of " morbillous fever" as it has been termed. De Haen, 
Morton, Vogel, &c, assert that cases of this kind frequently occur 
during an epidemic. Dr. Eberle observes : " It certainly is not uncom- 
mon during the prevalence of epidemic measles to meet with fever at- 
tended with the usual catarrhal symptoms of the malady, but unmarked 
by its peculiar eruption. Eichter observes that persons affected by 
these fevers are generally exempt from the disease during the subse- 
quent progress of the epidemic." 2 

It would, of course, be difficult to pronounce such to be cases of 
measles, nor have we any evidence to prove that the attack confers the 
usual immunity for the future, even though the patient may escape the 
disease during that epidemic. 

in. Many writers mention the occurrence of measles more than once 
in the same individual, but we must reject all such histories as were 
written before the distinction between scarlatina and measles was dis- 
tinctly laid down, and also all reports not authenticated by medical 
evidence, and then it seems probable that the cases will be much re- 
duced in number. Rosenstein says that in forty years' practice he 
never met with such a case; and Dr. Willan and others have made 
similar statements after twenty years' practice. 

Dr. Baillie has shown, however, that they may recur a second time 
in the same person, with febrile and catarrhal symptoms. 3 Dr. Dewees 
seems doubtful about it, except where the first attack may have been 

[ Bateman on Cutaneous Diseases, p. 63. 2 Diseases of Children, p. 429. 

s Trans, of a Society, &c, vol. iii. p. 253. 



696 MEASLES. 

the rubeola sine catarrho. Dr. Home mentions a case in which gland- 
ular enlargement followed measles, and after this had subsided in the 
course of six months the patient had measles again. 1 

Genovesi attended forty-six cases in Santa Cruz who had the disease 
before; and Duboscq de la Roberdiere prescribed during the epidemic 
at Vire, in 1777, for the persons whom he had cured in 1773. 

Dr. Eberle witnessed but one unequivocal example. 

Rayer mentions three instances which occurred to himself. 

MM. Guersent and Blache remark: "We have seen infants with 
measles twice in the same year. With one little child we observed in 
the space of six weeks two very irregular eruptions of measles, with 
varioloid occurring between. In another case the first eruption was 
mild, but the second, which occurred two months afterwards, was ex- 
tremely severe; and more recently a young girl of thirteen years, who 
had been treated by one of us for measles in her infancy, was attacked 
for the third time. This last eruption was extremely confluent, but 
she was free from bronchitis, and coryza appeared only on the decline 
of the disease." 2 

Dr. Condie mentions that several such cases have come under his 
notice. I have, in common with others, seen several cases of measles 
in persons who were said to have had the disease before, but I confess 
I never could quite satisfy myself about them. However, a short time 
ago one of my children was seized with the fever and catarrhal symp- 
toms of the usual duration, followed by the characteristic eruption, upon 
the hands first and most marked, then upon the face, body, and limbs, 
and which Dr. Stokes agreed with me was certainly measles. Yet I 
have a record, written at the time, of his having had the disease well 
marked seven years ago, and of other children having taken it from 
him. This time it has not been propagated. 

842. Other and much more important variations of measles have 
been noticed, dependent upon the predominance of some general cha- 
racter, or upon some particular state of the constitution. These may 
be very numerous if we take each complication as the characteristic, 
but I prefer leaving the complications for the present, and noticing 
merely the inflammatory, congestive, and typhoid type of measles. 

The prevalence of either of these types in any given epidemic, doubt- 
less depends upon what has been called the atmospheric constitution of 
the time, and, as this will determine the character of the treatment, it 
is essential that a well-informed physician should at all times ascertain 
this point. 

I. We may form a very good idea of measles with predominance of 
inflammatory character, or inflammatory measles, by supposing the 
description I have already given to be exaggerated many fold. The 
fever runs very high ; the pulse is rapid, full, and bounding ; the skin 
burning hot, and of a vivid color ; the eyes and nose incessantly run- 
ning ; the catarrh severe; frequent cough, dyspnoea, pain, &c, indicating 
some pulmonary complication ; headache, confusion of ideas, perhaps 
delirium or convulsions. Blood drawn exhibits the buffy coat. 

1 Med. Facts and Experiments, Mai. de la Peau, p. 148. 

2 Loco Citato, p. 677. 



MEASLES. 597 

The eruption appears early and copiously, is more prominent and 
more intensely red than usual, and the face is unusually swollen. 

This variety seems excited chiefly in children of a full, plethoric habit, 
who have been highly fed, and kept in close or warm rooms, or who 
suffer much from teething. The complications most common are con- 
vulsions, croup, pneumonia, and gastro-enteritis. 

ir. The congestive form is remarkable for a deficiency of vital energy. 
Reaction is tardy and imperfect; there is much depression; the face is 
pale, the features sunk and anxious ; the pulse labored and weak ; 
breathing oppressed, and the extremities cold. The eruption may not 
appear at all, or partially here and there. 

Children of a feeble constitution seem most liable to this form. In 
two cases of the kind related by Dr. Armstrong they died comatose and 
convulsed, and, upon examination, great engorgement of the lungs was 
detected. 

iii. The typhoid or malignant form of measles is characterized by 
the usual symptoms of typhus fever. The pulse is occasionally nearly 
natural, but more frequently weak and quick ; the skin is dry and burn- 
ing, and petechise may be observed in different parts. Colliquative 
sweats, diarrhoea, and hemorrhages occur, and the entire system is 
prostrated. 

Dr. Gregory thus describes this variety : " The eruptive fever is 
severe, and attended with unusual symptoms. The fever is typhoid, not 
inflammatory. The eruption appears too early or too late. It perhaps 
recedes after having shown itself, and partially reappears. The sto- 
mach is irritable ; vomiting is both severe and protracted ; there is deli- 
rium with wildness of eye, or coma; the belly is tender; there is purg- 
ing of unhealthy stools ; the extremities are cold, the pulse small and 
wavering. On the surface appear petechias or ecchymosed patches of 
eruption ; the fauces assume a livid or dusky red color; blood passes by 
stool ; there is much oppression at the prascordia, and abundant muco- 
serous discharge from the chest, indicating the congested condition of 
the lungs and their mucous membrane. In these almost hopeless cir- 
cumstances children may die in forty-eight or sixty hours, asphyxiated 
by the condition of the air-passages ; others die of coma or convulsions; 
some are worn out more slowly by diarrhoea and bloody stools." 1 

This form prevailed epidemically at Plymouth in 1745, in London in 
1763, and in Edinburgh in 1816. 

843. Complications. — I. Convulsions. — I have already alluded to this 
complication as occasionally ushering the disease ; it is not very com- 
mon, but we may now and then observe it in the inflammatory form, in 
the first period of measles or in the second, as the result, apparently, of 
reflex irritation. In most cases it appears a simple attack, and consists 
of a single convulsion ; but in others the convulsions are repeated with 
a train of symptoms indicating an inflammatory affection of the mem- 
branes of the brain, and in these we can discover traces of cerebral or 
meningeal congestion or inflammation after death. In almost all cases, 
the abstraction of blood by leeches, or counter-irritation of some kind, 

1 On Eruptive Fevers, p. 109. 



598 MEASLES. 

will be necessary, with free evacuation of the bowels ; but, for details, I 
must refer the reader to the chapter on convulsions. 

844. ir. Inflammation of the pharynx or larynx is a tolerably fre- 
quent complication of measles, as of scarlatina, but the larynx is more 
commonly the principal affection. The redness of the pharynx is slight, 
without swelling or ulcerated, but the mucous membrane of the larynx 
is often red, ulcerated, softened, or covered with false membrane con- 
stituting true croup. 1 In some few cases the croup may be spasmodic. 

The attack generally occurs about the third or fourth day; sometimes 
both the larynx and pharynx are affected simultaneously; in other cases 
successively. Nor does the complication prove so fatal as might have 
been expected, for, according to Guersent and Blache, a great propor- 
tion are cured when the measles are of a mild form; and in many child- 
ren who are carried off by some complication at a late period of the 
disease, very severe lesions of the larynx are observed to be in progress 
of cure. Much, however, will depend upon the constitution of the child 
and the character of the epidemic; occasionally we find this complica- 
tion prove very fatal. I have already indicated the treatment of second- 
ary croup. 

III. Broncho-pneumonia. — The most frequent and most important of 
these complications is inflammation of the bronchial tubes and lungs ; 
and although these two affections are distinct, yet are they so often 
combined, that Guersent and Blache consider them together, and with 
sufficient reason. Thus they met with twenty-four cases of bronchitis, 
seven of pneumonia, and fifty-eight of lobular broncho-pneumonia. 

This affection may occur during the preliminary fever, the decline of 
the eruption, or after the measles is apparently cured. But it is far 
more frequent during the first period ; and it is found to influence the 
course of the measles, just as its own course is influenced by the pri- 
mary malady. When it does not occur until the second period, it does 
not appear to modify the measles ; each disease runs its course, but the 
pneumonia has the character of a secondary disease. When it occurs 
after the disappearance of the measles, it is a primary disease, affected, 
doubtless, by the condition of the child, but generally lobar, unless 
other complications have intervened, in which case it is more frequently 
lobular. 

Dr. Gregory has given a very graphic picture of this complication : 
" It is a slow-creeping, insidious form of inflammation, which too often 
throws the practitioner off his guard. No positive complaint is made. 
The child droops and appears exhausted. Imagining that the disorder 
has weakened his patient, the practitioner directs some mild tonic. 
Meanwhile pneumonic engorgement (or pneumonia in its first stage) 
creeps on. The lungs become more and more congested, and at length 
solidified. Convulsive fits now take place ; alarm is taken, and leeches 
are applied, but the mischief is irreparable. Dyspnoea increases. The 
child becomes drowsy; the feet cold. The pulse sinks. Florid effusion 

1 Dr. Battersby's paper in Dublin Journal, vol. sxyiii. p. 67 ; and Dr. Lee's, ibid., vol. 
xxvi. p. 6. 



MEASLES. 599 

now takes place from the bronchial membrane. Another and another 
fit succeeds. Rattles are heard in the throat. The child dies I" 1 

In some cases we find bronchitis alone, or mixed with some nodules 
of lobular pneumonia, and so severe as to cause death; in other cases 
the pneumonia exists alone, but more frequently thej are combined, and 
the morbid appearances discoverable after death are those I have already 
described. 

During an epidemic in 1844, of 48 cases of measles under two years 
of age, treated by Dr. Lees, forty presented symptoms of pneumo- 
bronchitis; out of these, eighteen died ; four died on the second day of 
the eruption, and in them I found extensive lobar pneumonia in the se- 
cond stage, of the postero-inferior portion of both lungs, which I presume 
must have commenced previous to the eruption. In the other cases, 
a low form of secondary fever would appear, from the fifth to the eighth 
day of the disease; on the decline of the eruption, the infant had been 
going on well, when the mother would complain that it had passed a 
restless night, starting and burning with heat, particularly its hands, 
crying for drink or the nipple ; the cheeks were flushed, there was slight 
cough, hurried respiration, restlessness. A loose mucous rale could be 
heard all over the back of both lungs, which soon became a loud crepi- 
tus, with slight dulness ; the cough increased, and the infants died as if 
exhausted ; in two of the cases, where the ordinary symptoms of bron- 
chitis were absent, but where the dispnoea was extreme and great pallor 
of the countenance existed, I found extensive lobular pneumonia ; but 
in most of the cases I found vascularity of the pharynx, larynx, and 
bronchial mucous membrane ; patches of lobular pneumonia, in various 
stages, diffused through all parts of both lungs, with a tendency to be- 
come lobar at the postero-inferior portion of one or both lungs, and in 
the greater number of cases, tubercles scattered through the lungs, or 
infiltrated with cheesy deposits in the bronchial glands." 2 

The symptoms are those of pulmonary disease : cough, dyspnoea ; 
moist bronchitic or pneumonic rales, more or less intermingled, bron- 
chial respiration, vocal resonance, dulness on percussion, &c, as here- 
tofore laid down, but which may be overlooked in these cases, or con- 
founded with the ordinary catarrhal symptoms by superficial observers. 
In every case of measles, whether apparently complicated or not, the 
chest should be carefully examined at short intervals, and great care 
should be taken lest mild cases should be rendered severe or fatal by 
the complication, in consequence of the neglect of needful precautions. 

The attack seems influenced by age: thus, the younger the child, the 
more liable to pneumonia; at a more advanced age, bronchitis more 
commonly prevails. When the complication is developed during the 
first stage, it seems rather an extension of the irritation of the mucous 
membrane than owing to any special exciting cause. At a later period, 
it may arise from cold, sudden recession of the eruption, &c. Occa- 
sionally pneumonia is the characteristic of an epidemic. Dr. Dewees 
says: "We remember to have seen it epidemic in the spring of 1785 or 
1786, at which time almost every case was marked by pneumonic symp- 

1 On Eruptive Fevers, p. 106. 2 Dublin Journal, vol. xxvi. p. 9. 



600 MEASLES. 

tonis of greater or less violence. This disease was of difficult manage- 
ment; it ran its course with unusual rapidity; and not unfrequently 
terminated in death; and in all instances, almost, the cough was severe, 
obstinate, and of very long duration." 1 

iv. Pleuritis. — Guersent and Blache speak of this affection as of 
extreme rarity; but, if I may trust my own experience, I should be in- 
clined to think it much more common than has been supposed. I was 
consulted lately about some children who had got over the measles 
pretty well, but who were not recovering satisfactorily. Their princi- 
pal complaint, the mother told me, was a short cough and some pain in 
the side, but she mentioned the matter as rather trifling. Two of the 
children were brought to my house, and on examining carefully, I de- 
tected in each, pleurisy of the left side with great effusion, and displace- 
ment of the heart. 

The attack may occur during the first or second period, but I suspect 
that it is more frequent after the measles are over, as one of their sequelae. 
The symptoms may be very slight, as in the cases I have noticed, or 
they may be more severe, with high fever ; but we shall be certain to 
find cough, pain in the side, occasional or constant, with dulness on 
percussion, bronchial respiration, vocal resonance, unequal vibration, &c. 

I do not know that it is a very fatal complication, unless the child be 
much run down by the previous illness. It is certainly very tedious, 
and will require considerable attention and care. As I have before 
mentioned, it is seldom possible to bleed, but counter-irritation, with 
mild mercurials, and some expectorant mixture, answers very well. 
Diuretics I have also found very useful. 

845. v. Muguet, $c. — When speaking of the various forms of stoma- 
titis, ulcerated sore mouth, gangrene, &c, I mentioned that they occa- 
sionally occurred as secondary affections in the course of measles, but 
generally, also, as secondary to some disorder of the intestinal canal. 
It is not improbable that these diseases of the mouth are more fre- 
quently the result of the gastro-intestinal disorder than dependent upon 
the measles, and in treating them we must have respect to both complica- 
tions. They are more frequent in cachectic infants, and in those who 
are ill fed, and live in badly ventilated rooms. 

Gangrene of the pharynx is extremely rare ; much more so than gan- 
grene of the lung, but Wunderlich mentions it as occasionally occur- 
ring on recovery from measles. 

VI. Cr astro -enteritis. — Colitis. — Disorder of the stomach and bowels 
is so common in measles that few writers have omitted to notice it; and 
it has formed one of the divisions of several authors. "It is chiefly 
marked," Dr. Copland observes, "by accumulations of sordes in the 
stomach and bowels; by loaded tongue; pain and tenderness at the 
epigastrium, hypochondria, and bowels ; by morbid, bilious, and offensive 
alvine evacuations ; by the great severity of the cough ; by depression of 
the energies of the frame; the slower and less abundant eruption on the 
skin; by weakness and frequency of the pulse; and by severe pains in 
the lower limbs and forehead. It sometimes characterizes summer and 

1 Diseases of Children, p. 508. 



MEASLES. 601 

autumnal epidemics, particularly during or soon after warm and moist 
seasons; and it occurs sporadically in weak children during the periods 
of the first and second dentition, in the imperfectly nourished, and in 
those who have had their bowels long neglected." 1 

Vomiting and diarrhoea may accompany the invasion of measles, and 
the stomach afterwards regain its tranquillity, whilst the irritation of 
the bowels continues, or both may persist. 

Again, as we have seen, diarrhoea not unfrequently occurs towards 
the termination of measles, as a critical evacuation. 

Or, lastly, the symptoms of functional disturbance may assume the 
character of inflammation, and the disease assume a much more serious 
aspect, with tenderness and tension of the bowels, and especially of the 
epigastrium. 

Guersent and Blache found such cases rare ; in the majority there 
were no post-mortem evidences of inflammation. They remark that gas- 
troenteritis may complicate measles under any of its forms, either as 
acute or chronic, simple, dysenteric, typhoid, or cachectic. 

Colitis or dysentery occasionally occurs, but more rarely, accompa- 
nied with the usual symptoms of pain, tenderness, frequent and small 
evacuations of mucus mixed with blood. 

In thirty-seven cases Rilliet and Barthez found secondary normal 
entero-colitis ; in six, the chronic and cachetic ; in two, the dysenteric ; 
and in one, the typhoid form. 

In neither can we estimate the amount of febrile action due to the 
complication, because of the fever accompanying the measles. The 
pulse is always quick, the tongue coated, with thirst, heat of skin, &c= 

It is not easy to point out the causes of this complication ; probably 
much is owing to improper food, and much to impure air. Certain 
epidemics are thus characterized. Dr. Copland states that " Dr. Aber- 
crombie, of Cape Town, described to him an epidemic prevalence of 
measles in the colony, which presented much of this character ; the 
complication with diarrhoea, or enteritis, or dysentery — or the super- 
vention of them during the decline of the measles, or even some time 
after recovery from that disease, being very frequent and uncommonly 
fatal." 2 

846. VII. Ophthalmia. — We have seen that injection and suffusion of 
the conjunctiva, with increased secretion both of the mucous membrane 
and the lachrymal gland, characterized the first two periods of normal 
measles ; but this irritation subsides spontaneously in favorable cases, 
leaving a slight excess of sensibility only, for a few days. 

But in some cases, from the sixth to the twelfth day, the child has an 
attack of simple, or it may be of purulent ophthalmia, which may even 
terminate by the loss of sight. More frequently we see the conjunctiva 
of the lids chiefly affected, with some degree of swelling, redness of the 
membrane, lachrymation, secretion of mucus, sensibility to light, and 
incessant itching. The attack has no effect upon the course of the 
eruption. It may, however, have more serious results. Dr. Battersby 

1 Diet, of Practical Medicine, part ix. p. 815. 

2 Dictionary of Practical Medicine, part ix. p. 816. 



602 MEASLES. 

relates a case which ended in prolapse of the iris and staphyloma, and 
two others in which sloughing of the cornea occurred, 1 one of which 
died. It has heen remarked as prevailing very extensively in some 
epidemics, as the one mentioned hy Heyfelder, where it proved both 
troublesome and serious. 

Little active treatment is necessary in the ordinary forms. Fomen- 
tation with warm water, decoction of poppy-heads, or of chamomile 
flowers, in the first instance, with the addition of some astringent, as 
alum or zinc, or a weak solution of nitrate of silver when the disease 
becomes more chronic, and some counter-irritation, will generally be 
sufficient to cure the disease. When it depends upon the cachectic con- 
dition of the child, an improved diet, as convalescence advances, will 
act favorably upon the local affection. 

viii. Otitis. — Inflammation of the ear is not a very frequent compli- 
cation, though it occurs sometimes. It may occupy the external meatus 
only, or it may involve the deeper structures, and occasion permanent 
injury. Pain, more or less acute, deafness, sensibility to sound, and 
pain on pressure, will generally be present, and serve to point out the 
nature of the attack. It seldom occurs in the first or second period of 
the disease, but generally when the measles are disappearing, and is 
caused probably by cold. Dr. Condie speaks of its occurring in chil- 
dren of a scrofulous habit, and of its becoming chronic. 

Leeches, fomentations, and blisters will probably be found sufficient 
to relieve the disease ; but for further details of these two last com- 
plications I must refer my readers to the special works upon these 
diseases. 

ix. Hemorrhages. — I have already mentioned a modification of the 
eruption of measles which appears to be the result of ecchymosis, like 
purpura hemorrhagica ; but this disposition may extend to other in- 
ternal organs, such as the intestines most frequently, the kidneys, 
bladder, gums, or nose. Such complications are more or less import- 
ant in themselves, but far more as indications of a broken-down consti- 
tution, or a change in the composition of the blood, which may ulti- 
mately prove fatal. 

x. Eruptions. — Measles is followed by a variety of eruptions — herpes, 
eczema, porrigo, &c. ; either because the cutaneous excitement has left 
a disposition to morbid action, or because the state of the constitution 
is peculiarly favorable to these affections. " Porriginous eruptions on 
the head, and serous ulcerations behind the ears, also frequently occur, 
and, in some instances, induration of the mesenteric glands, and ma- 
rasmus. Among the occasional consequences are herpes, boils on 
different parts of the body, discharges from the ears, and anasarcous 
swellings." 2 

Dr. Lees mentions that, in most of his cases " an eruption of vesicles 
appeared on the wrists and spread over the body ; particularly large on 
the feet and ankles : it resembled scabies in appearance, but it was not 
itchy, and the vesicles were flattened." 

1 Dublin Journal, vol. xxviii. p. 77. 

2 Eberle on Diseases of Children, p. 435. 



MEASLES. 603 

Nor are these unfavorable. Dr. Armstrong remarks, that " when 
any cutaneous affections arise after measles, the internal organs remain 
free from disease ; and even when some internal disorder has existed, I 
have not unfrequently seen it disappear on the occurrence of some 
spontaneous eruption of the skin." 1 

XI. Tubercles. — In scrofulous children a rapid development of tuber- 
cular deposit not unfrequently dates from an attack of measles. It 
may show itself in glandular enlargement, mesenteric disease, or phthisis. 
Dv. Stokes states that more cases of tubercular phthisis come under his 
notice, who date their first symptoms from an attack of measles than 
from any of the other exanthemata. The occurrence has no essential 
connection with measles, but originates in the condition in which the 
eruptive disease leaves the constitution. 

xii. Anasarca. — This, which is so common a complication of scarla- 
tina, occurs also with measles, but much less frequently and much less 
seriously. Guersent and Blache observed it from the twelfth to the 
twentieth day, and in favorable cases it disappeared after a few days. 
In some cases it was more serious ; accompanied by albuminuria it ter- 
minated in death, and after death the kidneys exhibited the appear- 
ances of Bright's disease. 

xiii. Ulceration of Labia Pudendi and Rectum. — In foundling hospi- 
tals or poor-houses where many children are crowded together, and the 
atmosphere becomes vitiated, we occasionally find ulceration of the 
rectum, or, in girls, of the labia pudendi, which may either be simple 
or gangrenous, similar to that described by M. Kinder, Wood, and others. 
Sir William Watson mentions that, in the putrid form of measles which 
prevailed in the London foundling hospital, the girls who died most 
usually became mortified in the pudendum, and that one died of a mor- 
tification of the rectum. 

Dr. Lees relates two cases of ulceration of the rectum, and one in 
which both organs were affected, where " on dissection he found deep 
unhealthy ulceration situated in the inferior chordae vocales ; the mucous 
membrane of the trachea and larynx appeared in other respects to be 
normal. A large mass of crude tubercles occupied the centre of the 
left lung ; there was vascularity and thickening of the whole extent of 
the rectum, with superficial ulceration extending from the margin of the 
anus up the mucous membrane: there was great destruction of the labia 
with extensive ulceration in the surrounding parts." 

Thus, at the beginning of measles, the most formidable complication 
we have to fear is convulsions or meningitis ; during the early stage of 
the disease, laryngitis and broncho-pneumonia; at a later period, broncho- 
pneumonia and intestinal affection; and during recovery, disease of the 
lungs, intestinal tube, affections of the eyes, &c. 

847. Morbid Anatomy. — M. Fabre has given the following summary 
of the pathology of measles, independently of the eruption. When 
measles terminate fatally without any complication, the organs are 
generally found in a state of congestion, more or less marked, some- 
times of a blackish red color. Occasionally the follicles of Peyer and 

1 Practical Illustrations, fee, p. 175. 



604 MEASLES. 

Brunner are enlarged, as in scarlatina and smallpox, another analogy 
between these diseases and typhoid fever. The blood which is found in 
the vessels after death is black and fluid, and the cavities of the heart 
contain no coagula. The results of chemical analysis correspond to 
these characters; the fibrine preserves its mean proportion (3 parts in 
1000). M. Andral found in several adults attacked by measles, that 
the fibrine preserved the proportion of from 2J to 3J during the first 
stage, but that it diminished after the eruption. 

The proportion of red globules is augmented : from 129 in 1000, M. 
Andral found it as high as 137, 140, and 146. l 

Vogel placed the seat of the eruption in the epidermis ; more recent 
researches have shown that it occupies the rete vasculosa of the skin. 

I have not thought it necessary to describe the morbid appearances 
of any of the complicated forms of measles. I have already given the 
morbid anatomy of the different secondary diseases, and I must refer 
my readers to them. 

848. Causes. — That measles are infectious is admitted by all, but 
how soon the infectious effluvium is formed, and how far it may extend, 
is not settled. Dr. Williams thinks that the blood throws oft* infective 
emanations during the eruptive fever, and prior to any eruption. In 
the epidemic among the Feroe Islands, Dr. Panure states that it was 
communicated from one person to another, and that out of 6000 there 
was not one tending to prove the existence of " morbillose miasmata." 
No case occurred to prove that the contagion was communicated either 
during the period of incubation or of desquamation ; but in all during 
the eruptive stage. Much will probably depend upon the virulence of 
the disease. It may also be carried from the sick and communicated 
to third parties; the party conveying it participating in the attack with 
the others, and at the same time. It is said also that it may be con- 
veyed by a person who does not take the disease to third parties, and 
some cases I have heard would seem to justify this conclusion. 

But in addition to its infectious nature, and to its facility of convey- 
ance by woollen or porous bodies, it may also be spread by contagion 
and by inoculation. Vogel, Wachsel, Brown, Munro, and Tissot, pro- 
duced measles by inoculation with the blood of a person laboring under 
the disease, or with the serum of the vesicles which are occasionally 
mixed with the eruption. It was hoped that inoculation might be as 
successful with measles as with smallpox, in exciting a milder form, but 
this has not been found to be the case, and the practice has never pre- 
vailed. 

" By a recent notice in one of the Austrian medical journals, it ap- 
pears that Dr. Katona, of Borsoder, in Hungary, has tested, in a large 
number of cases, the efficacy of inoculation for measles. In a very 
fatal and wide-spread epidemic, which prevailed during the winter of 
1841, Dr. Katona inoculated 1122 persons with a drop of fluid from a 
vesicle, or with a drop of the tears of a patient affected with the dis- 
ease, the fluid being inserted in the same manner as the virus in vacci- 
nation. The operation succeeded in about 93 per cent, of the cases in 

1 Bibliotheq. du M^dicin.-prat., part xvii. p. 448. 



MEASLES. 605 

which it was performed, producing a mild attack of measles. A red 
areola at first formed around the puncture by which the fluid was in- 
serted, but soon disappeared. On the seventh day the fever com- 
menced, with the usual prodromi of measles ; on the ninth or tenth day 
the eruption made its appearance ; on the fourteenth, desquamation 
commenced, with a decrease of the febrile symptoms; and by the seven- 
teenth day the patients were very generally well. In no one of the 
inoculated cases did the disease terminate fatally." 

It occurs also as an epidemic, owing probably to some peculiar state 
of the atmosphere, and is certainly conveyed and propagated by it, 
and frequently an epidemic of measles follows immediately one of hoop- 
ing-cough, both commencing with an affection of the bronchial mucous 
membrane. The following are some of the principal ones : — 

An epidemic was observed in London in 1769, 1770, 1773, 1774, and 
described by Sydenham ; in Upsal in 1752, described by Rozen ; at 
Plymouth in 1741, by Huxham ; in London in 1763 and 1768, by 
Watson ; at Vire in 1772 and 1773, by Poliniere and Le Pecq de la 
Cloture ; in Paris, in the years 6 and 7 of the Republic ; by Consbruck 
in 1800, 1801 ; in Edinburgh, in 1816 ; in Paris in 1828, and again in 
1833 ; in Hungary in 1841 ; and in the Hopital Necker in 1843. In 
Boston it first appeared as a very fatal epidemic in 1713 ; and again in 
1730, 1757, and 1772. Of late it was most frequent in the years 1821, 
'25, '29, '32, '35, and '46. 

Dr. J. Duncan has described an epidemic of measles which occurred 
in the North Union Poor-house, between March and June, 1842 : 56 
children were attacked, and 15 died ; 11 were under one year, 10 be- 
tween one and two years, 22 between two and five years, and 13 above 
five years. The complications were as follows ; in 12 cases, there was 
pneumonia ; in 13, convulsions; in 8, bronchitis ; in 4, phthisis ; in 5, 
croup ; in 1, peritonitis ; in 3, ulcerated tonsils ; in 4, prolapsus ani 
succeeded ; and in 5, ophthalmia succeeded. 1 Dr. Lees has published 
a valuable paper upon the complication of measles in the epidemic of 
March, April, and beginning of May, 1844, at the North Union Poor- 
house of Dublin ; 147 children were attacked, of whom 35 were between 
2 and 5 years of age of age, and 6 died : 112 were between 5 and 12, 
and of these only 5 died. The chief complications were broncho-pneu- 
monia, laryngitis, enteritis, peritonitis, &c. Dr. Coley has described a 
malignant epidemic which prevailed in London during the winter 1847-8. 

Such epidemics are frequently characterized by the predominance of 
one or other complication, and their mortality generally depends upon 
this, and the type of the disease. 

849. The origin of the disease is quite unknown ; it has been attri- 
buted to minute insects in the air, or to some unknown composition of 
the atmosphere ; but we can prove nothing. It is transported, either 
by atmospheric influence or by individuals, to distant countries, although 
it is not always possible to mark its transit, and some distant lands 
seem to escape it altogether. 

Thus it is stated by M. d'Angheira to have been imported into Ame- 

1 Dublin Journal, vol. xxii., Sept. 1842, p. 2G. 



606 MEASLES. 

rica in 1518 ; and Dr. Stewart says there are no records of its appear- 
ance in North America before 1713. It appeared for the first time in 
St. Helena in 1808, and the same year it returned to Madeira after an 
absence of five years. 

" A few years ago," says Dr. Copeland, " measles were introduced 
into the Cape of Good Hope, where they had not appeared for about 
thirty years, by a vessel from Europe, in which several instances occur- 
red during the voyage." 1 

In Australia, Van Diemen's Land, and New Zealand, I believe, it is 
unknown to this day. 

Sporadic cases of measles are observed at all seasons ; but epidemics, 
according to M. Andral, occur especially towards the end of winter and 
in the spring ; so that the season of the year influences the latter, but 
not the former. 

I have already shown that the age of the child is so far a predisposing 
cause, that more infants are attacked than children, and more children 
than adults ; and I endeavored to explain this without supposing a 
greater inherent liability. Nor is the foetus in utero exempt from the 
disease. Hildanus, Roesler, Vogel, Rosenstein, Osiander, Girtanner, 
Orfila, Billard, and others, witnessed cases of this kind. 2 

I saw a case in which the eruption of measles appeared upon both 
mother and child the second day after delivery. In these cases, of 
course, the disease must have been communicated to the foetus through 
the blood of the mother, and so far are evidences of its contagion, analo- 
gous to the cases of inoculation. 

From the calculations of Emerson 3 and Condie, it appears that 395 
deaths occurred between the ages of one and two years, and only 468 
between the ages of two and five years. Of 1293 deaths, which occur 
red in London in 1842, 4 93.8 per cent, occurred in children under five 
years, and 99 per cent, in those under ten years. 

Rilliet and Barthez met with 25 cases between one and two years ; 
72 between three and five years ; 50 between six and ten years ; and 20 
between eleven and fifteen years. 

850. Diagnosis. — It is, of course, very difficult to pronounce upon 
the nature of the disease during the first stage, nor would it be very 
wise to do so. The sudden access of fever, the running of the eyes and 
nose, the hoarse voice, &c, may well excite our suspicions, but they will 
not be confirmed until the eruption appears. Then the semicircular or 
crescentic form of the eruption, mixed with papulge, their elevation and 
their course, will clear up our doubts. 

I. It may be distinguished from scarlatina by the distinctive form of 
the eruption, its elevation, and the greater disposition to affect the 
respiratory organs. In scarlatina, the eruption is diffused, and scarcely 
at all elevated — more, in fact, like a vivid blush than an eruption ; the 
digestive organs are more affected, and the cellular tissue. 

I have, however, repeatedly met with cases in which for some time 

1 Diet, of Pract. Med., part ix. p. 822. 

2 Ueber der Krankheiten des Foetus, by Grsetzer, p. 46. 

3 American Journal of Medical Science, 1827, vol. i. 

4 West on Diseases of Infancy and Childhood, p. 476. 



MEASLES. 607 

the diagnosis was extremely difficult. The eruption may resemble either 
disease, or one disease on one part of the body, and the other on 
another, and there may be an absence of the usual affections of the 
mucous membranes. 

As a general rule, if there is neither coryza, sneezing, nor coughing, 
I should conclude that the disease was not measles ; but I am not sure 
that this rule is absolute. There are, however, two circumstances, either 
of which may determine a doubtful case. 1. Other members of the 
family may exhibit the disease in its orthodox form, and so clear up our 
doubts ; or, 2. Some of the definite sequelae may follow, and be equally 
conclusive as to the nature of the previous eruption. 

II. Some cases of roseola strikingly resemble measles, and no doubt 
have been mistaken for them ; but, in general, there is little or no run- 
ning of the nose and eyes, no catarrh, less fever, the eruption is more 
fugitive, and no desquamation takes place. Moreover, when measles 
attacks one child of a family, it is generally communicated to others, 
which is not the case with roseola. 

851. Prognosis. — The prognosis in the mild uncomplicated form of 
measles is almost always favorable ; but, although a considerable num- 
ber do recover, many others die. Percival states that 91 died out of 
3807 cases ; Watson, that 1 in 10 in one year, and 1 in 3 in another, died 
in the Foundling Hospital, London ; Home estimates the deaths at 1 in 
12 ; M. De la Garde lost 3 per cent. 

We must, therefore, take other matters into consideration before 
forming our prognosis — the epidemic character, the type of the disease, 
and its complications. 

The concurrence of pneumonia, croup, gastro-enteritis, or dysentery, 
whether they prevail epidemically or not, diminishes the chances of 
recovery very seriously. The typhoid form of the disease is also by far 
the most fatal. And children of broken-down constitutions are more 
likely to fall victims to the complaint than those who were previously 
healthy. 

Upon the whole, measles are far less fatal than either scarlatina or 

)OX. 

Of 167 cases, Rilliet and Barthez state that 77 were cured, and 90 
died, and the conclusions they draw are as follows : 1. That normal 
primitive measles, simple, or with slight inflammation of the respiratory 
or digestive organs, is very easily cured. 2. Normal primary, but com- 
plicated measles, is cured about as often as it proves fatal. 3. Anoma- 
lous measles, primary and complicated, is as often curable as mortal. 
4. Simple secondary anomalous measles is fatal to half the cases, but 
the mortality depends upon the primary affection, and not upon the 
measles. 5. Anomalous complicated secondary measles is fatal in the 
great majority of cases. 1 

" The favorable indications which occur during the disease are a 
moderate eruption, with a mitigation of the fever ; a disposition to an 
equable moisture on the skin ; a moderate or slight cough, with a mu- 
cous and easy expectoration; a free and unembarrassed respiration; a 

1 Mai. des. Enfans, vol. ii. p. 744. 



608 MEASLES. 

free state of the bowels, and moderate relaxation of them towards the 
close of the disease ; hypostatic urine ; a regular succession of the 
changes of the eruption ; and no appearance of any irregularity or com- 
plication with visceral aifection, the existence of which often occasions 
a fatal result at a more or less remote period, owing to the tendency to 
disorganization being greater in the local affections occurring, than when 
taking place primarily." 1 

852. Treatment. — As the disease has a definite and regular course, 
we cannot attempt to interfere with that, but must content ourselves 
with correcting anything unfavorable in the type, and to subdue, if 
possible, the complications. 

In a simple case of measles, very little treatment will be necessary : 
the bowels must be kept free, and plenty of diluent drinks allowed ; the 
patient to be kept in bed, lightly covered, and only a very light diet per- 
mitted. 

The heat and prickling or itching of the skin, when the eruption 
appears, may be relieved by small doses of the liquor ammonias acetatis 
and spiritus setheris nitrici. The catarrhal symptoms may be soothed 
by a mucilaginous mixture, with ipecacuanha, and a small quantity of 
morphia. Drs. Willan and Fothergill give emetics for this purpose, 
and they certainly seem to mitigate the fever. 

I quite agree with Dr. Armstrong, who observes : "From an impar- 
tial consideration of the facts which have come before me, I am con- 
vinced that our plan of treating measles (in its regular form) is too uni- 
formly active when the eruptive fever is developed ; and that we should 
be more fortunate in the main if we interfered less with the operations of 
nature in cases of a mild and regular character." 2 

Until the disease has subsided, the diet should be moderate ; it may 
then be increased gradually; the child must live in warm, well-venti- 
lated apartments, and every precaution must be taken to avoid cold. 

853. In the inflammatory form of the disease, when not only the 
surface but the mucous membrane, and even the lungs, are in a state of 
extreme congestion or inflammation, more active measures will be neces- 
sary, and these of an antiphlogistic kind. 

Sydenham advises bleeding, when the fever is violent, with pulmonary 
symptoms. Cullen thinks it rarely necessary early in the disease. 
Willan and Bateman prefer reserving it until a later period, if it should 
then be required by the cough, dyspnoea, pain in the chest, &c. 

There is no doubt that bloodletting is quite admissible in measles, if 
the symptoms demand it, but regard must be had to the character of 
the epidemic ; and it is to the variations of this character that we must 
ascribe the difference of opinion in authors, each of whom speaks accord- 
ing to his experience. Thus Hamilton, Murray, and others, did not 
employ it, whilst Mead, Heberden, Home, Fergusson, Armstrong, &c, 
regarded it as a necessary part of the treatment. 

Dr. Dewees observes : "Therefore regard must be had to the charac- 
ter the measles assume, and must be treated accordingly. If fever be 

1 Copland, Diet, of Pract. Med., partix. p. 821. 

2 Practical Illustrations of Scarlet Fever, Measles, &c, p. 115. 



MEASLES. 609 

high, cough and oppression severe, blood should be drawn immediately, 
though these symptoms occur at rather an uncommon period of the 
disease, namely, in its forming stage ; for such changes may be imposed 
upon the character of measles by some constitution of the air or other 
cause, as to render this operation occasionally necessary." 1 And he adds, 
that he had only bled once that season, though he had prescribed for 
more than 100 patients. 

Drs. Stewart, Condie, and West, advocate the employment of bleed- 
ing when the inflammatory symptoms run high, or any pectoral compli- 
cation exists. 

The quantity of blood to be taken must depend partly upon the inten- 
sity of the febrile or inflammatory action, partly upon the organs prin- 
cipally affected, and partly upon the stage of the disease and the con- 
stitution of the child. If the child be strong, the lungs considerably 
involved, with a quick pulse, sufficient blood should be taken to make a 
decisive impression upon the disease. On the contrary, at an advanced 
stage of measles, with delicate children, we must use great caution, and 
perhaps have recourse to leeches instead of venesection. 

In Germany much benefit is said to be derived from mustard poultices 
after leeching; and in my own practice, I have found them very useful 
applications. 

Other antiphlogistic remedies must also be adopted; low diet, cooling, 
diluent drinks, saline effervescing draughts, &c, with a brisk purgative 
of calomel and rhubarb, or jalap, or castor oil. 

If there be no gastric irritation, we may give minute doses of tartar 
emetic with some expectorant, by which the cough will be relieved, and 
the general excitement lowered. If the skin be dry, James's powder, 
with a small portion of Dover's powder, may be given at bedtime, or 
twice in the day. 

Cold affusion has been strongly recommended, or sponging the body 
with cold water; and we are assured that there is neither the risk one 
would suppose of suppressing the eruption, nor of exciting internal in- 
flammation. 3 Dr. Armstrong does not think it as suitable as in scar- 
latina, but he has derived great benefit from tepid affusion. 3 

854. In the congestive form of measles, if we detect any organic in- 
flammation, it may be found necessary to bleed, and it will generally be 
found that the pulse improves afterwards. Then we may have recourse 
to external counter-irritants, calomel and opium, &c. 

Warm baths will be found of great service in exciting the cutaneous 
circulation, and so relieving the internal organs ; and, moreover, they 
will favor the free development of the eruption. 

Diffusible stimulants are of use ; carbonate of ammonia in almond milk 
affords great relief in congestion of the lungs. 

855. In the typhoid or malignant form of measles, bloodletting will 
be out of the question. Our object must be to support and stimulate the 
vital powers, for which purpose we must give ammonia, camphor, bark, 

1 Diseases of Children, p. 570. 

2 Bateman on Cutaneous Diseases, p, 61. 

3 Practical Illustrations, p. 163. 

39 



610 SCARLET FEVER. 

the alkaline carbonates, the chlorides, &c. Wine also may be necessary, 
and good diet. 

Guersent and Blache speak favorably of injections of bark, the use of 
rubefacients, mustard poultices, or blisters to the extremities, &c. 

856. The practitioner, I must repeat, must always be guided in his 
treatment by the epidemic character of the season, and by the pecu- 
liarity of the epidemic of measles. Thus, purgatives must be cautiously 
administered when gastro-enteritis, or diarrhoea, or dysentery prevails ; 
bloodletting used warily when diseases have a typhoid or adynamic cha- 
racter. * 

In inflammatory epidemics, such as that described by Mead, Arm- 
strong, &c, bleeding is highly beneficial ; but in the one that prevailed 
in Paris in 1828, although it was frequently complicated with inflam- 
mation of the lungs and other organs, M. Biett states that it was not 
benefited by bloodletting. 1 

857. Special treatment will be required for each of the complications, 
whether of the brain, lungs, or gastro-intestinal canal; but of this I 
have so fully spoken under the head of each of these diseases, that I 
need not recapitulate the matter here. 



■ m 

CHAPTER II. 

SCARLET FEVER — SCARLATINA. 

858. The second of the eruptive fevers I shaM notice is scarlatina. 
Like measles, it is preceded and accompanied by fever ; and after a few 
days, a rash appears which is general, and of a vivid red, with much 
irritation of the mucous membranes, especially of the threat and stomach; 
it runs a definite course; occurs epidemically; may b# propagated by 
infection or contagion, and ordinarily attacks a person but once in a 
lifetime. Its cause and history have so much resemblance to measles 
that for a long time they were confounded, but the eruption is quite 
different in its general diffusion, and the digestive mucous membrane, 
rather than the pulmonary, is chiefly affected. 

It is a disease of infancy and childhood emphatically, and I believe 
for the reason I have already mentioned, viz: that being highly infec- 
tious as well as epidemic, the child takes it the first time it is exposed to 
its influence, which is pretty sure to happen before it has passed many 
years, in consequence of the frequent prevalence of the disease. 

Of 2614 cases recorded by Mr. Farre in his Fourth Report, 2419 
were children, 182 adults, and 13 aged persons. 

Dr. Copland says that it is doubtful whether scarlet fever was known 
to the Greeks or Romans. Ingrassias is said by Hildenbrand and Frank 
to have been the first to distinguish the disease. Cottyer published an 

1 Report in Jour. Hebdom., No. 42. 



SCARLET FEVER. 611 

account of an epidemic -which resembled scarlatina, and which prevailed 
in Poitiers in 1557. And Forestius states that the epidemic at Amster- 
dam in 1517, which was described by Tyengus, was this malady. 1 Mer- 
catus (1672), Heredia (1626), Sgambatus (1620), iEtius Clerus (1686), 
Senner (1625), Sydenham, Sibbald, Morton, Fothergill, Heberden, De 
Haen, &c. &c, have since described the disease. It first appeared in 
Spain in 1610, in Naples in 1618, in London in 1670, and in Edinburgh 
1680. 

859. We can only form an approximate estimate of the frequency of 
scarlatina. 

Dr. Copland has given the number of deaths from scarlatina, measles, 
and smallpox, in the eleven years from 1838 to 1848 inclusive, and 
those are: from scarlatina, 20,962; from measles, 14,632; and from 
smallpox, 13,079. " In only three of these years have the deaths by 
measles been greater than those by scarlatina, and in only two has the 
mortality from smallpox exceeded that of scarlet fever." 

Mr. Wilde observes that it is " the tenth most fatal of the epidemic 
class of diseases, and destroyed (in the ten years) 7886 persons, the 
sexes being in the proportion of 100 males to 95.97 females. With the 
exception of cholera, this disease has proved more fatal in towns, and 
among large and closely united masses of the population, than any 
other epidemic of this country, being one death in 24.63 of the epidemic 
affections in the civic districts, and but 1 in 65.07 in those of the same 
class in the rural districts or open country. The deaths specified from 
this cause are in the proportion of 1 in 150.56 of the total recorded 
mortality, and 1 in 48.34 of the entire epidemic or contagious dis- 
eases." .... "In the years 1835-36, and part of 1837, the mortality 
from this disease rose from 620 to 840, 1074, and 1040, being then the 
forerunner of the fever, and smallpox which prevailed in 1837, 1838, 
and 1839, during the continuance of which diseases it fell, but again 
rose up, then declined in 1840. " 2 

In the tables of mortality of Philadelphia, U. S., published by Dr. 
Emerson, it appears that in twenty-four years the mortality from scar- 
latina was 143 under twenty years'of age; and during the first twenty 
years of this period, there were 654 deaths from measles. 3 

During the ten years preceding 1845, Dr. Condie states that there 
were 2154 deaths from scarlatina, and only 574 from measles. 

Guersent and Blache have added together the cases collected in 1838- 
9, by Roger, Rilliet and Barthez, and Barrier, and find that there were 
157 cases of scarlet fever, 264 of measles, and 213 of variola and vario- 
loid. 4 

Dr. Gregory mentions that the deaths from scarlatina in 1837 in 
London were 2520; in 1838, 5802; in 1839, 10,325; and in 1840, 
19,816. 

Thus we cannot draw any accurate comparisons of the frequency of 
measles and scarlatina, or estimate precisely the frequency of either 

1 Diet, of Pract. Med., part xiv. p. 665. 

2 Report on the Table of Deaths, p. 13. 

3 American Journal. of Medical Science, 1827, vol. i. 

4 Diet, de Med., vol. xxviii. 



612 SCARLET FEVER. 

disease. The irregular occurrence of an epidemic of either disease, or 
its unusual severity, will effectually disarrange our statistical calcula- 
tions. 

860. Scarlatina may be either primary or secondary, normal or 
abnormal. By most writers it has been divided into three varieties, 
scarlatina simplex, scarlatina anginosa, and scarlatina maligna. 

I shall adopt the same plan as with measles, and first describe the 
ordinary form of scarlatina, and then the deviations or modifications. 

We may notice three periods of the disease. 

I. The Period of Invasion. — The term of incubation, from the mo- 
ment of receiving the infection to the development of febrile symptoms, 
varies in different patients: it may be only a few hours, or it may 
extend to ten or twelve days; in some cases of Dr. Maton's it appeared 
to be twenty-four or twenty-five days. 

The earliest symptoms which manifest themselves are general unea- 
siness, lassitude, depression, aching in the back and limbs, rigors, loss 
of appetite, and thirst. Soon afterwards the patient complains of stiff- 
ness and pain in the throat, with difficulty and pain in swallowing. 

The skin becomes very hot, the pulse quick and full; occasionally 
there is nausea and vomiting; always pain in the loins, headache, and 
either drowsiness or sleeplessness. 

When the initiatory fever runs very high, there may be delirium or 
even convulsions; the latter especially, if the infant be teething — but 
seldom more than one or two. 

The face is congested, swollen, and red; the eyes injected, and sen- 
sitive to light. If the fauces and throat be examined, they will be found 
puffy, red, and inflamed, and the tonsils swollen. The tongue is white 
or yellow, and loaded at the base, but red at the point and edges, with 
prominent papillae. 

The fever during this time seems rather to increase, the skin is hot 
and florid, the thirst intense, and the pulse very quick. 

The bowels are generally confined, the urine is scanty, high-colored, 
and voided frequently; sometimes it is albuminous, but more commonly 
so at a later period. 

After these symptoms have continued for a time, varying from one 
day to four or six, the eruption makes its appearance. 

861. II. Period of Eruption. — -At first there appear a number of 
minute red points, on a rose-colored ground, about the face or neck; 
sometimes on the trunk or extremities. These rapidly increase, spread, 
and coalesce into large patches, which increase and coalesce until the 
entire surface of the face, body, and limbs, is covered. Or the face and 
body may be occupied fully by the rash, whilst it exists in irregular 
patches on the limbs. 

Neither the minute red points, nor the large patches, nor the generally 
diffused rash, have either tangible or visible prominence; the skin feels 
rough if the finger be passed over it, and the surface of portions, as the 
face, may be swollen ; but the characteristic appearance is that of a 
vivid scarlet color, like that of a boiled lobster, without papulae; very 
different from the irregular, semicircular or crescentic, somewhat ele- 



SCARLET FEVER. 613 

vated eruption of measles. Under pressure, the bright scarlet color 
disappears, and returns when the pressure is removed. 

The skin is burning hot, dry, and rough, resembling "goose-skin" to 
the touch ; the itching is often intense, and the face, feet, and hands 
are considerably swollen. The pharynx is of a vivid red; the tonsils 
are red, swollen, and often covered with white pultaceous secretion in 
patches: the swelling of the tonsils may be perceived externally, and 
the submaxillary glands are also enlarged. 

The coating of the tongue gradually peels off, until it presents the 
appearance peculiar to this affection ; it is dark-red, dry, and shining 
as if varnished, with prominent papillae, something like the surface of 
raspberry jam, if I may use so homely a comparison. 

On certain parts of the body, as the neck, axillae, folds of the arm, 
&c, we find occasionally an eruption of miliary vesicles. 

The fever generally subsides some degrees upon the appearance of 
the rash, and continues at that point until it finally disappears. The 
heat of the skin during the eruption is very great ; Hasse, Cuvier, 
Andral, and Rayer, have found it to range from about 90° to 112° 
Fahrenheit. 

When the attack is severe, or during a paroxysm, the countenance 
is excited, but expressive of suffering ; the eyes are bright ; there is 
restlessness, agitation, or delirium, and the patient is generally sleep- 
less ; the respiration is hurried, and often impeded ; the constipation 
may be replaced by diarrhoea to a certain amount, accompanied with 
slight colic. 

It is chiefly during this period that the more serious complications 
are developed. 

" After five, six, or eight days," Guersent and Blache observe, " that 
is, after a longer time than was required in measles, the exanthema 
gradually subsides ; it assumes a violet tinge, then a pale rose, or 
slight copper color. Most commonly the mucous membrane of the 
mouth remains red, sometimes it is at this period only that the tongue, 
throwing off its white coating, presents the prominent papillae, and the 
characteristic redness. The swelling of the parts diminishes simulta- 
neously, but gradually." 1 

862. in. Period of Desquamation. — Somewhere, then, between the 
fourth and ninth day desquamation commences. If the attack have 
been severe, the fever high, and the eruption abundant, the process may 
commence before the disappearance of the rash, but more generally it 
is after its decline, during convalescence, or perhaps not until a week 
or two after its disappearance. It observes prett}' much the order in 
which the eruption appeared ; the miliary vesicles drying first. 

When the eruption has been very slight, the desquamation is some- 
times scarcely perceptible ; in other cases the epidermis is detached in 
very minute powdery particles, like flour : more frequently, however, 
it comes off in scales of varying sizes, or in strips from those parts 
where the epidermis is very thick, as the hands, fingers, soles of the 
feet, &c. 

1 Diet, de Med., vol. xxviii. p. 153. 



614 SCARLET FEVER. 

The epithelium of the tongue is also cast off, leaving it of a vivid red 
color, and sometimes very tender. 

The hair commonly falls out in great quantities, and several writers 
have noticed the nails falling off. Dr. Graves mentions a case of this 
kind. 

This process may last from eight to fifteen days, or even longer, from 
thirty to forty ; but then we observe repeated exfoliations. Occasionally 
the skin becomes universally sensitive during desquamation, and with 
some infants the slightest contact is very painful. Other children suffer 
from a kind of rheumatic pain in the limbs or joints, but chiefly in the 
wrists, during this or the preceding period, which does not, however, 
last as long as ordinary rheumatism. 

Sometimes between the fifth and eighth day, or sooner if the attack 
be slight, we find the pulse become quiet, the surface cooler, though the 
skin is still dry and rough, and the affections of the digestive or respi- 
ratory mucous membrane diminish, and finally disappear. The throat 
ceases to be painful, the swelling of the tonsils subsides, and the pharynx 
and vault of the palate lose their scarlatinous redness. 

Abundant alvine evacuations, profuse sweating, or more rarely nasal 
hemorrhage, mark the critical termination of scarlatina. 

Thus the entire duration of the disease will vary much, as well as each 
stage. In the mildest form, it may occupy five or six days ; in others, 
several weeks. 

863. Modifications. — I have thus sketched a marked but simple case 
of scarlatina. Our next point is to notice the principal modifications 
which may arise in the character of the eruption and its course, or in 
the type of the disease. 

a. The eruption may be partial, occupying only the face and hands, 
the neck and chest, or the flexures of the joints. Or the redness may 
be in extremes, either very slight or very deep ; or a number of violet- 
colored points may be interspersed, or a crop of miliary vesicles — the 
scarlatina miliformis of P. Frank; these vesicles are sometimes mixed 
with sudamina or papulae, but very rarely with pustules. 

" Reuss, Raimann, and Hildenbrand have observed, in rare instances, 
the eruption, on the second day of the efflorescence, of bullae, of a dark- 
red color, above the size of a nut, containing a yellowish serum, and 
resembling that produced by a blistering plaster. The cuticle breaks, 
and, the fluid being discharged, a sore remains, which follows the course 
of the constitutional malady." 1 This is the scarlatina ptemphigoides of 
Hildenbrand. 

In the severe forms of the disease, the eruption may assume a dark- 
red or livid color, occasionally interspersed with petechiae of various 
sizes, or even large patches of sanguineous effusion, constituting the 
scarlatina purpura. 

Most writers have noticed the appearance of miliary vesicles. Rayer 
mentions having seen coincident eruptions of variola and chicken-pox. 2 

b. There may be also deviations from the usual course of the disease; 

1 Diet, of Pract. Med., part xiv. p. 668. 

2 Diet, de Med. et de Chir. Prat,, vol. xiv. p. 541. 



SCARLET FEVER. 615 

the initiatory fever may be either longer or more brief than usual, and 
the' eruption consequently make its appearance after four, five, or six 
days, or almost simultaneously with the outbreak of the fever. 

In four out of seven children in one family, the children were free 
from any symptom whatever until vomiting took place, after which the 
disease ran its usual course. Two of my own children were apparently 
quite well up to 5 P. M., when they were suddenly attacked by vomit- 
ing, followed by fever ; and in the morning they were scarlet, but with- 
out sore throat, and had little or no desquamation. This absence of 
sore throat, or any other specific complication, if the rash be not very 
characteristic, renders the case very puzzling, and, in fact, we may not 
be able to pronounce positively upon the case until either the disease 
attacks other members of the same family, or some of the peculiar 
sequelae make their appearance. 

The rash may die away unusually quickly, or remain longer than 
ordinary, or it may recede from especial causes. I have already men- 
tioned its recession and reappearance in some cases. 

Lastly, the desquamation may be scarcely perceptible, or may occupy 
weeks. 

864. It appears also, from very good evidence, that a child may have 
scarlatina without the eruption, or die before the eruption appears. Some 
have doubted this ; but it is maintained by Huxham, Fothergill, Stoll, 
Dance, Guersent, Graves, Trousseau, and others. We may see the dis- 
ease run its regular course with several members of a family, and per- 
haps one of them will exhibit all the constitutional symptoms, fever, 
sore throat, &c, without any rash upon the skin. 

I have seen one well-marked case of this kind. 

We may perhaps go further, for Dr. Copland believes that " a child 
in the same house or family, in which scarlet fever is unequivocally 
present, may c have the constitutional aifection, not only without the 
characteristic eruption, but even without the sore throaty also ; both 
these essential features of the malady being either entirely wanting, or 
so slight and so evanescent as to escape notice." This Dr. Copland 
believes to be true scarlatina, though latent. 

Dr. Graves has related a case of a young lady who was in constant 
attendance upon her sisters during scarlatina, and who exhibited no 
symptom of the disease, but who was attacked by the anasarca of scar- 
latina after the other children were convalescent. 1 

We find such occurrences more common in certain epidemics than in 
others, but it is always necessary to regard them carefully and cau- 
tiously, " for it should not be overlooked that sore throat and fever, 
both the local and constitutional affections being characterized by re- 
markable asthenia, amounting evenjh putro-adynamia, may occur spo- 
radically or endemically, or even ^epidemically, independently of any 
connection with scarlatina, and amongst persons and families who have 
already been the subjects of scarlatina. Of these occurrences I have 
met with several instances, the greater part of a family, all of which 
had previously had scarlet fever, having been thus attacked." 2 

1 Clinical Medicine, vol. i. p. 347. 2 Diet, of Pract. Med., part xiv. p. 868. 



616 SCARLET FEVER. 

865. The modifications which depend upon the type of the epidemic, 
or perhaps upon the constitution of the patient, have been usually 
divided into three varieties : 1, the scarlatina simplex vel mitis ; 2, 
scarlatina anginosa ; and 3, scarlatina maligna. 

This peculiar type varies in different epidemics, owing to the " consti- 
tutio morborum" as it has been called. Thus, for years, all the scarla- 
tina may be attended with inflammatory symptoms, then an epidemic 
may occur of a typhoid character, and as other diseases illustrate the 
prevailing constitution, by ascertaining that, we may and ought, in 
some degree, to be prepared for the type of the epidemic of scarlatina. 

Rilliet and Barthez give three forms, answering nearly to the above. 
In the first, the symptoms are very slight, as it were incomplete ; in the 
second, the eruption is slight and benign, but the general symptoms are 
severe, and run an irregular course ; in the third, the typhoid character 
pervades all the symptoms. 

I. Mild Scarlatina may prevail in certain districts, or even epide- 
mically. Cases of it also occur during severe epidemics, and may be 
followed by dropsy or other of the ordinary sequelae. It is characterized 
by the moderate character of the symptoms I have already described. 
The initiatory fever is short and slight ; the eruption moderate and brief; 
the fever mild ; the throat but little distressing, although on examina- 
tion it exhibits its usual character ; the desquamation trifling, perhaps 
inappreciable. The entire course of the disease is short, and patients 
recover from it rapidly and completely, unless from imprudence some of 
the usual complications or sequelae should occur. 

II. Scarlatina Anginosa. — In this variety the description I have 
already given of the disease is considerably aggravated. The fever is 
intense ; the inflammation of the throat severe, and the tonsils much 
swollen, and covered with patches of whitish or grayish lymph ; the 
temperature of the body often rises to 104, or even, according to Dr. 
Condie, to 112; the pulse is rarely under 120; the tongue is white, 
and loaded with enlarged papillae. The eruption may appear upon the 
third day, or not till later ; sometimes it disappears and returns ; in 
some cases it is faint, but in most very well marked. The skin is burn- 
ing, the thirst excessive, and the difficulty and pain of swallowing very 
considerable. Delirium is very common as the fever increases towards 
night. 

But the point of most importance, next to the inflammatory character 
of the fever and the severe aifection of the throat, is the liability to 
internal complications, either of the brain, lungs, digestive organs or 
kidneys, &c, of which I shall speak presently. 

This form of the disease may characterize the epidemic or individual 
sporadic cases, nor is it the most dangerous form. 

866. in. Scarlatina Maligna may commence like the latter variety, 
and may by degrees assume its peculiar typhoid character. It usually, 
however, presents an asthenic or typhoid character from the begin- 
ning, especially in autumn and winter, in patients of a debilitated con- 
stitution. " The patient is first affected with languor, lassitude, weak- 
ness, and vague pains through the body. These are succeeded by 
chilliness or shivering, followed by great heat. These latter alternate 



SCARLET FEVER. 617 

for several hours, until at last the heat becomes more constant and 
intense. The patient then complains of faintness, great pain in the 
head, and of violent sickness, with vomiting or purging, or both, espe- 
cially in children, more rarely in adults. Heat and soreness are felt 
in the throat, and stiffness and tenderness in the neck. The face soon 
appears red and flushed, swollen, or bloated, occasionally pale and sunk ; 
the eyes are red, watery, heavy, or suffused. There are great fretful- 
ness, restlessness, anxiety, lipothymia or faintness, and remarkable de- 
jection of spirits. The pulse, from the first, is quick, small, and flut- 
tering ; in some, soft and full, but weak and irregular, but always with- 
out that firmness and strength observed in inflammatory diseases. Dr. 
Johnston remarks that if blood be taken from a vein soon after the 
attack, instead of forming a firm crassamentum, " it continues in the 
state of gelatinous texture." The urine at first appears crude, like 
whey ; as the disease advances it becomes yellower, as if bile were 
diluted with it, or turbid, scanty, high-colored, and sometimes it con- 
tains dissolved or decomposed blood-globules. At the same time as, or 
soon after the attack, the fauces, uvula, tonsils, and pharynx become 
red and swollen, and soon afterwards covered in parts by ash-colored 
or dark exudations, which appear as sloughs. The tongue is now deep 
red or brown, dry and glazed, and sometimes so tender and chapped as 
readily to bleed. The throat soon acquires a dusky red, brown, or 
livid hue, and the exudations on the fauces and tonsils are darker, and 
often cover gangrenous ulcers. The febrile or constitutional disturbance 
presents an extremely typhoid or asthenic character, or putro-adynamia. 
The skin is hot, but there is little thirst, although the mouth is dry, 
and the teeth and lips are covered by sordes, or by an acrid fluid from 
the excoriated or ulcerated sore throat. The breath is remarkably fetid 
and contaminating." 1 

It may, however, commence mildly, and to a certain extent progress 
very favorably to all appearance, when suddenly the throat again be- 
comes sore, and the parotid and submaxillary glands swollen and pain- 
ful, and typhoid symptoms of the worst kind set in. Dr. Graves has 
given a very graphic account of this variety, to which, and to. all his 
most valuable observations upon scarlatina, I beg to refer the reader. 2 

Dr. Armstrong observes, that it is " in general only when the fever 
is protracted beyond the fourth day that the ulcers are converted into 
ill-conditioned, black, and fetid sloughs. At the commencement the 
affection of the throat may be only pseudo-membranous pharyngitis; but 
at a more advanced stage, and in bad cases, ulceration takes place, and 
assumes a gangrenous character." 

The eruption may appear on the second or third day, or not until 
later, and then it has not its usual florid appearance, but rather re- 
sembles a dusky red stain. It may disappear and return, and it may be 
accompanied by petechia, or some degree of oedema. The parotid and 
submaxillary glands are swollen and tender, and the neck and throat 
become oedematous, with great dyspnoea. There is an acrid discharge 
from the nostrils and mouth, the angles and edges of which are exco- 

1 Diet, of Pract. Med., part xiv. p. 670. 2 Clinical Medicine, vol. i. p. 318. 



618 SCARLET FEVER. 

riated by it, and the mouth often assumes an aphthous appearance. The 
gangrenous ulceration of the throat may extend up the Eustachian tube, 
and the tympanum and bones of the ear be destroyed by it, an acrid 
offensive discharge escaping from the ear. 

" When the disease has 'assumed a particularly violent character, col- 
lapse supervenes towards the middle or end of the second week. Great 
prostration of the vital energies now ensues ; the pulse becomes very 
frequent and feeble ; the heat of the surface sinks ; the tongue is dark 
brown, or black ; exhausting diarrhoea often takes place ; and, in some 
cases, hemorrhages from various parts, and petechise, occur towards the 
fatal termination of the complaint." 1 

The febrile excitement in children may run on into a low muttering 
delirium, or perhaps more frequently into stupor and coma. 

" In the more violent cases the efflorescence either disappears or 
becomes livid, the fauces are black and the breath most offensive ; the 
eyes lose their lustre, and the swelling of the neck increases. The stools 
and urine are evacuated involuntarily ; the former being frequent, 
watery, and most offensive, sometimes bloody; the latter putrid, brown- 
ish, or suffused. The surface becomes cool ; the countenance bloated, 
cadaverous, or ©edematous; the parts pressed upon, excoriated or sphace- 
lated ; the tongue brown, hard,, or dry ; the breathing labored, or inter- 
rupted by singultus ; and death follows with insensibility, congestion of 
the lungs, and great alteration of the state of the blood, and of all the 
circulating and secreted fluids." 2 

In several cases of fatal malignant scarlatina that I have seen, the 
eruption was not unfavorable, perhaps less florid and profuse than usual, 
but not unusually so, and the patients had but very slight sore throat ; 
but the case exhibited marked typhoid symptoms, with dry, dark, loaded 
tongue and sordes about the teeth, and ran on into coma, and some- 
times convulsions. 

Death may occur as early as the second day, either from the laryn- 
geal, pharyngeal, or cerebral complications, or at a later period from the 
cerebral or pulmonary complications, or from the morbid state of the 
blood. 

This phase of scarlatina is distinguished from the others by the 
typhoid character of the fever, the malignant affection of the throat, and 
the adynamic complications of the cerebral, thoracic, or abdominal 
organs. 

As to the comparative frequency of the different forms, Dr. Willan 
states that in 1786 he saw thirty-nine cases of malignant, to 152 of the 
anginose variety; and Dr. Clarke, of Newcastle, had thirty-three cases 
of malignant to seventy-three of the anginose form. 

867. Dr. Armstrong has described three varieties of malignant scar- 
latina : the inflammatory, the congested, and the mixed. The first 
commences, like scarlatina anginosa, with considerable inflammatory 
excitement, but, after a few days, collapse and a typhoid condition 
supervene; the vital powers sink, the throat becomes gangrenous, and 

1 Eberle, Diseases of Children, p. 449. 2 Diet, of Pract. Med., part xiv. p. 671. 



SCARLET FEVER. 619 

the other characteristic symptoms appear. It answers to the putrid 
variety of Richter. 

The second is characterized by a want of reaction : " The subjects 
of this modification are for the most part suddenly attacked. They 
become pale, faint, and sick, and chiefly complain of pain, load or gid- 
diness in the head, extreme oppression, and much uneasiness in the 
region of the heart or at the pit of the stomach. Sometimes they at 
once sink, as if overcome by an uncommon shock, and lie in a state of 
confusion and oppression without making much complaint. At other 
times they walk about, pale and languid, for two or three days, and then 
take to their beds like persons completely worn out by some great 
fatigue or mental anxiety. When the attack has once decidedly occur- 
red, the respiration is either quick and anxious, or slow and impeded. 
There is often a mixture of livor and paleness in the face ; the eyes are 
frequently dull, but sometimes glairy, and they acquire a fatuous or 
inebriated expression in the course of the disease. The mind, at first 
alarmed, confused, or dejected, soon becomes disordered with delirium ; 
or an indifference to surrounding objects and a stupor succeed, under 
which patients finally expire. From the beginning the pulse is gene- 
rally low, quick, and irregular, and commonly continues. so to the last; 
but in those cases where there is a very slight degree of reaction, it 
sometimes has a short and rather sharp feel for a certain period, and 
finally grows weak and undulating. At first the tongue is commonly 
whitish in the middle, paler than natural, and covered with a slimy 
saliva, but towards the close it often becomes rough and darkish, and 
then the breath is usually offensive. The bowels are commonly dis- 
tended with flatulency, constipated or irregular in the first stage, but 
frequently loose in the last. The faeces are sometimes darker, at other 
times lighter than natural. The stomach is often extremely irritable ; 
yet occasionally it retains everything that is taken, though the degluti- 
tion becomes more difficult as the disease advances. This form of the 
scarlet fever frequently runs its fatal course in two, three, or four days 
from the occurrence of the extreme general oppression, and there are 
almost always appearances of putridity in the last stage, such as oozings 
of blood from the mouth or nostrils, dark hemorrhages from the bladder 
or bowels, inky petechias, or gangrenous spots upon the skin. A few 
hours before death there is often a superficial glow of heat diffused over 
the body, accompanied with a darkly flushed face, high breathing, 
accelerated pulse, and partial or general sweats. But this mere sem- 
blance of excitement soon subsides ; the extremities grow cold, the face 
assumes a cadaverous hue, and when the skin is pale it often has almost 
the smooth waxen appearance of the surface of a corpse." 1 

In this form the eruption -is of a purplish or copperish color, deepen- 
ing as the disease advances, and sometimes quickly disappearing. In 
some rapid and fatal cases the throat is but slightly affected ; in others 
there are specks or sloughs on the fauces, but not disproportioned to the 
amount of general disease. 

These varieties, as I have already observed, depend partly upon the 

1 Practical Illustrations of Scarlet Fever, &c, p. 21. 



620 SCARLET FEVER. 

condition of the child and partly upon the character of the epidemic, 
some assuming the form of scarlatina anginosa, and others of scarlatina 
maligna. 

A very interesting question is as to the increase in the intensity of 
the poison in proportion to the number of children affected in the same 
house. In one family where seven were attacked, the two last affected 
exhibited the worst typhoid character of fever, but with very slight sore 
throat; one died on the third day, and the other on the sixth. 

868. The last modification I shall notice is when the disease occurs a 
second time in the same person. No doubt, as I said of measles, that 
in many cases which are popularly deemed a second attack of scarlatina, 
one of the affections was roseola ; but there are undoubted cases on re- 
cord of the recurrence of scarlatina, although they are rare. 

Willan observed no such case. Jos. Frank and M. Bayer each met 
with one case. Heberden says that such cases occur. Dr. Wood saw 
five in forty-five cases. Berton, Rilliet and Barthez, and Heyfelder, 
mention one case each. 1 Dr. Burns mentions two instances. Dr. Bate- 
man regards such cases as exceptions to a general rule. Bicker, 2 New- 
man, 3 and Burns, deny that the susceptibility is invariably removed by 
one attack. Richter observes that a second and even a third attack has 
occurred. 4 

Dr. Meigs, Jun., mentions the case of a person who had the disease 
two year previously under the care of his father. 5 

869. Complications. 6 — The complications of scarlatina vary much as 
to the period at which they occur, ranging from the earliest incursions 
of the disease until weeks after its apparent cure. They differ also in 
character, in part owing to the violence of the attack, in part to the 
character of the epidemic, and a good deal according to the constitution 
and habits of the patient. They are quite different among the poor, ill- 
fed, scantily-clothed children of the poor, from those met with among 
the rich. Something also depends upon the age of the child, as an in- 
fant who is teething is much more liable to convulsions or head affections. 

a. Affections of the, Mouth. — When speaking of muguet, aphthas, 
ulcerated sore mouth, and cancrum oris, I mentioned their occurrence 
during the course of scarlatina. 7 In ordinary scarlatina anginosa we 
may frequently perceive a disposition to the deposition of lymph upon 
the tonsils in the early stage of the disease; but if the case be favorable, 
it extends no further into the mouth. But in some of the severe cases 
of scarlatina maligna, in an advanced stage, aphthae, or ulceration, may 
be observed in the mouth or about the gums ; and these ulcers may take 
on a gangrenous character, and become converted into cancrum oris. 
Such a complication would probably itself insure a fatal termination, 

1 Diet, de Med., vol. xxviii. p. 173. 

2 Beschreibung eines Scharlachfiebers, p. 162. 

3 Aufsatze und Beobacht. fur Aertze, p. 284. 

4 Specielle Therapie, vol. ii. p. 440. 5 Diseases of Children, p. 448. 

6 I would take the liberty of referring my readers to Dr. H. Kennedy's little volume on 
scarlatina, as containing a valuable series of facts illustrative of almost all the complica- 
tions of scarlatina, as they occurred for a number of years iu this city, carefully noted 
and simply related. 

7 Section iv. chapters 4, 5, 6, 7. 



SCARLET FEVER. 621 

were it not that in most cases that is secured by the general typhoid 
form of the fever, and the gangrenous condition of the throat. 

b. Pharyngitis. — In its moderate form, we can hardly call this a 
complication of scarlatina ; it is rather a part of the disease itself. It 
commences during the preliminary fever, with redness and swelling of 
the fauces and throat, with soreness and difficulty of swallowing. Soon 
afterwards slight patches of false membrane appear upon the tonsils, 
which may coalesce and extend to the neighboring parts ; the submaxil- 
lary glands and tonsils are felt externally to be much enlarged and 
tender ; deglutition is impeded ; the fluids, or a portion of them, are re- 
gurgitated ; and the speech is less clear than usual. If the complication 
be very extensive and severe, it will predominate over the other symp- 
toms : "the febrile reaction becomes intense ; the oppression great ; re- 
spiration impeded ; the cough frequent, rarely clear and sonorous, but 
also rarely hoarse or lost ; the face is excited ; but in some cases ex- 
presses prostration, anxiety, and suffering ; and, the disease continuing 
to make progress, the patient dies when the angina has existed from five 
to ten days." 1 

But this pseudo-membranous pharyngitis is by no means the worst 
form of sore throat met with in the severe forms of scarlatina. Instead 
of the whitish patches lying upon the inflamed but unbroken mucous 
membrane, we may find ulceration of the tonsils, spreading to the 
pharynx, and exhibiting an unhealthy, grayish surface, which speedily 
assumes a gangrenous character. Or we may find the pharynx, tonsils, 
and fauces, covered more or less with grayish or brownish patches, un- 
derneath which ulceration of an unhealthy character is going on ; and 
by and by, when these membranous layers are thrown off partially or 
wholly, we may discover ulcers of various shapes and extent, but gene- 
rally deep, which assume a gangrenous appearance. In whichever way 
it commences, we may have very shortly to deal with that very formi- 
dable and fatal affection, gangrene of the pharynx, or putrid sore throat, 
which I have heretofore described, 2 and the danger of which is increased 
by its occurrence in the course of a typhoid form of disease. 

c. Grastro-enteritis. — This is seldom a very formidable, though by no 
means a rare complication, unless it should prevail epidemically at the 
same time as scarlatina. Vomiting not unfrequently occurs during the 
first stage, or even the second, but rarely afterwards. Diarrhoea often 
marks the crisis when the disease is about to decline, and so far may be 
rather beneficial. 

Dr. Copland mentions that, in the cases in which this complication 
occurred, the eruption was either suppressed, partial, scanty, or pre- 
vented from appearing; the throat, moreover, being more or less affected. 

Dr. Graves noticed vomiting and purging, accompanied by abdominal 
tenderness, and he attributes it to cerebral irritation and congestion, as 
in hydrocephalus. 

Dr. Gregory speaks of a low degree of mucous enteritis accompanying 
the decline of scarlatina, and, in bad cases, ending in ulceration of the 
mucous membrane, with bloody stools. 3 

1 Rilliet and Barthez, Mai. des Enfans, vol. ii. p. G04. 

2 Section iv. chap. 11, p. 478. 3 On Eruptive Fevers, p. 134. 



622 SCARLET FEVER. 

But in the scarlatina maligna we have occasionally a very severe 
attack of diarrhoea at an advanced stage, with flatulence, tympanitis, 
and some degree of tension and tenderness. Although at this period, 
and in this form of disease, the gastro-enteric affection does not consti- 
tute the principal danger, it certainly adds to it, and may hasten the 
fatal termination. 

870. d. Coryza. — In some cases the inflammation of the mucous 
membrane of the throat is extended to the nose, and there is irritation, 
sneezing, &c, with a mucous or muco-purulent discharge. In the ad- 
vanced stages of scarlatina maligna there is an acrid discharge, which 
excoriates the edges of the nostril. But this complication is of no im- 
portance ; it is but a symptom, and has no bearing upon the issue of 
the disease. 

e. Laryngitis. — In some cases, though not very frequently, when 
there is much ©edematous swelling of the neck, the glottis and neighbor- 
ing parts participate in the affection ; and from the situation of the 
glottis, a sudden incursion of oedema may prove very serious ; in fact 
the child may be choked very suddenly. We should, therefore, always 
be prepared for this occurrence, and watch the throat very carefully. 
It is, however, very rare. 

Simple laryngitis may also complicate scarlatina, though it is not 
common. It is much more probable that the diphtherite will extend to 
the larynx, and give rise to the symptoms of secondary croup, 1 as in the 
cases described by Mr. O'Ferrall. Such an addition to the original 
disease will, of course, add to its formidable character. It rarely occurs 
during the period of invasion, but generally about the appearance of the 
eruption, or soon after. 

I do not know that there are any cases on record of gangrene of the 
larynx in scarlatina. I have never seen it ; hut I can easily suppose 
that the gangrene might extend from the pharynx to the larynx. 

/. Pneumonia. — In severe attacks of scarlatina anginosa, the lungs 
are much congested, or even occasionally inflamed ; but it does not 
appear to be at all so common as in measles. 

In the congestive form of scarlatina maligna, the lungs participate in 
the congestion of all the internal organs, and this congestion may run 
on into inflammation. During convalescence, if the child be exposed to 
cold, lie may very probably suffer from an attack of pneumonia. 

f/. Pleurisy. — This complication occasionally occurs in scarlatina, 
sometimes during the first or second stage, when inflammatory symp- 
toms run high, but more frequently when the eruption is declining, or 
during convalescence. Both this secondary affection and pneumonia are 
of such importance that we should be ever on the watch to detect their 
earliest symptoms. 

871. h. Cerebral Affections. — I have already mentioned that the 
child may be attacked by delirium, headache, stupor, convulsions, coma, 
or paralysis. These may occur at any period ; headache and delirium 
occur generally during the first stage, and are but rarely permanent. 
However, they may assume a more serious character, and prove fatal. 

1 Graves, Clinical Med., vol. i. p. 320. 



SCARLET FEVER. 623 

One child of a patient of mine died suddenly of apoplectic congestion of 
the brain just as the eruption was appearing. Her sister sank into a 
state of stupor and died suddenly without convulsions. MM. Guersent 
and Blache mention a case in which delirium, with loud cries, came on 
during convalescence, with vomiting, but no other symptom, and lasted 
some days. Rilliet and Barthez mention that cerebral complications 
proving fatal are more frequent in scarlatina than any other fever. 

I saw a case in which the head symptoms were relieved by bleeding, 
and the child was apparently going on well, but two or three days 
afterwards, without warning, convulsions attacked the child and proved 
rapidly fatal. Dr. Graves mentions several cases in which convulsions 
occurred on the first or second day, followed by coma, and ending 
fatally. 1 Generally speaking, there are but one or two convulsions: 
but, in other cases, I have known the convulsions continue with all the 
other symptoms of meningitis, and prove fatal. Low, muttering deli- 
rium occurs in scarlatina maligna. During the desquamation and con- 
valescence, the nervous symptoms which occur, the coma and paralysis 
which come on suddenly, seem to be connected in many cases with the 
dropsy, of which I shall speak presently. 

On dissection, the cause of the cerebral symptoms is seen to be owing 
sometimes to excessive congestion of the brain, and sometimes to inflam- 
mation of its membranes, 2 or effusion into the ventricles. 

i. Diffuse Inflammation and Glandular Swellings of the Neck. — We 
have seen that the tonsils and submaxillary glands are more or less 
swollen, and in some cases the parotids, one or both, participate in this 
enlargement, which may be very considerable. And not only that, but 
the entire neck may be so much swollen from cellular oedema as to 
place the patient in great danger of suffocation. 

Dr. Graves and Dr. H. Kennedy describe this as a very formidable 
complication. Sometimes it attacked the patient during the height of 
the eruption, in others after the constitutional symptoms had in a great 
measure subsided. It spread with great rapidity round the neck, which 
became immensely enlarged, the swelling extending from the face to the 
clavicles, in some cases, and in one, involving even the pectoral muscles. 
At first it appeared to consist of serum, afterwards unhealthy pus, either 
infiltrated through the tissues or collected into small abscesses, or form- 
ing one large one. In many cases, sloughing of the most formidable 
character set in, with great destruction of tissues, and occasional and even 
fatal hemorrhage from disordered vessels. The edges of the sores while 
sloughing were either of a dark red or livid hue, and in two or three 
instances quite black. Dr. Kennedy has mentioned another species of 
swelling which was caused by the effusion of lymph; the neck became 
swollen and very hard, and very rarely small abscesses formed. It was 
also sometimes more limited in extent than the diffuse inflammation. 

Dr. Asbery has described a very formidable and fatal complication 
of diffuse inflammation of the neck which he noticed in the epidemic of 
1840-41. "The progress," he says, "of the inflammation was very 

1 Clinical Med., vol. i. p. 313. 

2 Guersent and Blache, Diet, de Med., vol. xxviii. p. 101. Rilliet and Barthez, Mai. 
des Enl'ans, vol. ii p. (320. 



624 SCARLET FEVER. 

insidious, in most cases commencing as an indurated swelling behind 
the angle of the jaw on one side, which was at first very indolent, with- 
out any discoloration of the integuments, but as the affection advanced 
the swelling increased much more rapidly, often extending to the oppo- 
site side; the integuments then assumed a dusky red appearance, and 
became very tender to the touch ; there was much oedema, so that the 
part readily pitted, when pressed by the finger, and there was an obscure 
sense of fluctuation communicated to the touch. In the advanced stage 
of the complaint, sensibility, which was previously great, diminished to 
such a degree that the child did not seem to suffer much pain, if inci- 
sions were made into the swelling. When the patient survived till about 
the tenth day from the commencement of the affection, sloughs fre- 
quently formed, commencing in dark purple specks over the surface of 
the swelling, the sloughing rapidly spread, diarrhoea then set in; the 
abdomen became tympanitic, spots of purpura appearing, at times, over 
the surface of the body, until the occurrence of passive hemorrhage from 
the mouth and bowels. The child either died comatose, or exhausted by 
diarrhoea, in case dissolution was not quickened by the supervention of 
sudden hemorrhage from some of the large vessels of the neck giving 
way in sloughing. An attack of convulsions sometimes preceded death, 
the period of which, unless precipitated by exhausting treatment to 
which it had been submitted previous to my seeing the child, varied from 
the seventh to the twenty-eighth day; the medium time being about the 
twelfth day from the commencement of the inflammation." 1 Dr. Graves 
also relates a case of this kind, and he agrees with Dr. Asbery that all 
our efforts should be directed to support the strength of the patient 
until sloughing takes place, and afterwards. 

Dr. West observes that "in the majority of instances, however, the 
glandular swellings, which come on after the lapse of a week from the 
commencement of the disease, though tedious and painful, yet do not 
endanger life. Occasionally, indeed, death occurs in consequence of the 
matter formed by the inflammation of the glands, or of the cellular tissue 
around them, burrowing backwards behind the pharynx, instead of 
pointing externally. In these cases of retro-pharyngeal abscess, after 
more or less evident indications of inflammation in the neighborhood of 
the parotid or submaxillary glands, accompanied in all probability, with 
a swelling on one or other side of the jaw, the patient begins to expe- 
rience difficulty in deglutition, which goes on increasing until the 
attempt to swallow becomes quite impracticable. As the dysphagia 
increases, respiration also becomes very difficult, but the dyspnoea con- 
tinues to increase progressively, and is not aggravated in paroxysms, as 
in cases of cynanche trachealis, though the effort to swallow will often 
bring on threatening suffocation. However, there is seldom any modi- 
fication in the tone of the voice, such as occurs in croup, though the 
voice becomes by degrees whispering, and then extinct; while if the 
throat be examined, the tonsils are observed to be free from swelling; 
and sometimes neither they nor the soft palate show the slightest in- 

1 Graves, Clinical Med., vol. i. p. 333. 



SCARLET FEVER. 625 

crease in redness, or other token of inflammation." 1 I have already- 
laid before the reader Dr. Flemyng's remarks upon the retro-pharyn- 
geal abscess, with the mode of cure, and I must refer him to that chap- 
ter for fuller details. 2 A teasing consequence of this affection of the 
neck has been noticed by Mr. 0. Ferrall and Dr. H. Kennedy, viz: wry- 
neck remaining when the patient was becoming convalescent. Whether 
it be mechanically owing to the remains of the swelling, or the effect of 
inflammation upon the muscles, or the consequence of disease of the 
vertebras, as Mr. 0. Ferrall suggests, it is difficult sometimes to decide. 
The neck is crooked, and any attempt to straighten it gives great pain. 

872. j. Dropsy. — Albumen. — The dropsy which accompanies or fol- 
lows scarlatina has been noticed from early times by all authors. It 
was a subject of special investigation to Plenciz, De Borsieri, Vieus- 
sieux, Meglin, &c, and is treated of by Underwood, Dewees, Eberle, 
Stewart, Condie, Maunsell and Evanson, Coley, West, Barrier, Billiet 
and Barthez, Legendre, Johnson, Bush, Toynbee, Simon, &c. 3 

The complication is a very interesting one, and worthy of ample 
details. M. Legendre thus describes the affection: — "The anasarca 
which is developed during the desquamation of scarlatina is very dif- 
ferent in its mode of invasion, its course, and its symptoms, from that 
which results from a state of cachexia, or from an obstacle to the course 
of the blood. In the anasarca consecutive to scarlatina the face is 
puffed, but tense, elastic, and does not preserve the impression of the 
finger; the eyelids themselves, which are often so much swollen that 
their separation is diminished, are resistant. The face does not present 
that dead paleness which is observable in passive anasarca; on the con- 
trary, from the accompanying febrile action, there is generally a red 
color in the cheeks. The enlargement of the trunk and members is 
equally characterized by a remarkable elasticity, so that pressure bj 
the finger leaves no trace, and decubitus on the side does not determine 
a greater quantity of serum on the side in which the patient lies, nor 
does the skin assume the paleness and transparency of passive dropsy. 
From these peculiarities, it is possible that the enlargement might be 
supposed to result from 'embonpoint' by a person who had never seen 
the patient before ; but this is not possible when the anasarca has lasted 
some time, and has increased rapidly under the influence of certain 
serious complications, for then the distension of the subcutaneous cellu- 
lar tissue becomes considerable, accompanied with paleness and trans- 
parency of the skin, and the serum, displaced by pressure of the finger, 
and obeying the laws of gravity, is accumulated on the side on which 
decubitus has taken place. If the eruption of scarlatina has not been 
very slight, or if much time have not elapsed, the skin will present some 
traces of desquamation at the moment when the dropsy is developed ; if 
not on the trunk, yet on the feet or palms of the hands. The general 
symptoms which precede the anasarca commonly diminish after its 
appearance, leaving merely a degree of fever, which in some infants is 
perceptible only in the evening. Most frequently, after five or six ds 

1 Diseases of Infancy and Childhood, p. 474. 

2 Chapter xii. p. 440. 3 Med.-Chir. Trans., vols. sxix. and xxx. 

40 



626 SCARLET FEVER. 

these febrile symptoms disappear, either under the influence of treat- 
ment, or naturally; but when they are prolonged, and accompanied by 
new symptoms, either cerebral, pulmonary, or abdominal, there is rea- 
son to fear some serious complication in either of these regions. Lastly, 
the urine presents in this anasarca peculiar characters, which have struck 
diiferent observers, though in different ways. Some have mentioned the 
peculiar aspect of the urine ; others have given their analysis." 1 

In some cases, the anasarca may be very slight, and yet the attack 
prove fatal from the effusion of fluid into some of the cavities. In two 
cases under my care, soon after, a moderate degree of anasarca showed 
itself, with suppression of urine at first, then bloody, but not albumin- 
ous urine, and at the same time cerebral symptoms were developed, 
heaviness, constant stupor, insensibility, and, in one case, convulsions 
and death ; the other child recovered. 

In another case, convulsions occurred after the urine had become 
natural, and the anasarca had nearly disappeared. 

The extreme limits of the period at which the dropsy makes its 
appearance after scarlatina are from ten to forty days. Borsieri, Wells, 
and others, say between the twentieth and twenty-third day, generally ; 
Rayer about the fourteenth or fifteenth, or later. 

It may, however, occur much earlier, even during the eruption. Dr. 
Asbrey relates a case who died anasarcous on the fifth day from the 
commencement, 2 and another when it appeared on the second day. 

It is sometimes preceded by vomiting, diarrhoea, abdominal pains, 
and fever, but not always; it may come on quite insidiously and slowly, 
or with suddenness and rapidity. It ordinarily commences in the face, 
and from thence extends over the body in the course of two or three 
days. 

873. Plenciz and Rosenstein were the first to notice that in this form 
of dropsy the urine was scanty, and resembled the water in which flesh 
had been washed. Dr. Wells, as the result of his researches, added, 
that the red color of the urine was owing to a mixture of blood, and 
that the action of heat determined a floury precipitate, of a dirty brown 
color, after the separation of which the urine became clear. 

Different opinions have been maintained in explanation of this condi- 
tion of the urine, and its connection with the dropsy, and different 
views held of the condition of the kidneys in this disease. Seymour, 
Barlow, Spittal, Graves, Lees, and others, regard the renal disturb- 
ance in the dropsy of scarlatina as functional, on account of its cura- 
bility, whereas Bright's disease involves an organic change in the 
kidneys. 

Others, however, as Hamilton, Wood, Mateson, Constant, &c, con- 
sider the anasarca with coagulable urine as dependent upon Bright's 
disease of the kidney. M. Bayer regards the continuance of albumi- 
nous nephritis as leading to the establishment of one of the three forms 
of Bright's disease. 

Lastly, MM. Guersent and Blache, although believing in the exist- 

1 Recherches Anat. Path, sur plusieurs Mai. de l'Enfance, p. 343. 

2 Dub. Journal, vol. xxiii. p. 239. 



SCARLET FEVER. 627 

ence of acute albuminous nephritis when the urine is coagulable after 
scarlatina, yet do not consider this nephritis as the cause of the dropsy, 
because of the great number of cases of dropsy in which the urine is 
not coagulable. 

The facts which appear to be certain are these : in some cases of 
dropsy with albuminuria, and which proved fatal, the kidneys have 
been found in a state of hyperemia, resembling the first stage of 
Bright's disease, as in instances related by Fischer, 1 Hamilton, 2 and 
others ; and Bright, Christison, Guersent, and Blache, have found the 
granulations, so characteristic of albuminous nephritis, in other more 
chronic cases. But, on the other hand, there are many cases of ana- 
sarca, without albuminuria, of albuminous urine without any change in 
the kidneys, as in Dr. Graves and Dr. Lees' cases, and also of albumi- 
nous nephritis without dropsy, as Rilliet and Barthez have remarked, 
and as was the case in the epidemic at Berlin, described by Dr. Philip, 
and in some cases which occurred in Dublin, as noticed by Dr. H. Ken- 
nedy, 3 and as I have repeatedly seen. 

874. M. Legendre, in his valuable memoir, has minutely reported 
fourteen cases, and I shall be excused, I am sure, if I give in some 
detail the result of his observations. As to the color, when the anasarca 
had existed only three or four days, the urine was sometimes blackish, 
or perhaps only of a red color, more or less deep ; after eight or nine 
days this red color was superseded by a brown color, something like 
muddy beer ; and as time elapsed, and the disease diminished, the urine 
became of a lighter color, until, about the fifteenth or eighteenth day, 
it was paler than natural ; and when the renal affection had ceased, it 
became quite natural. These different shades of color depended upon 
the presence of blood, as was easily ascertained by the microscope. 
Even after the urine became quite natural, colorless blood-globules could 
be detected by the same means. At the same time, the urine lost its 
usual transparency ; muddy or troubled when first passed, it became 
clear after standing, and deposited at the bottom of the vessel either 
small clots or reddish or brownish flocculi. 

The specific gravity was slightly diminished ; less so than in Bright's 
disease. When heat was applied, or nitric acid added, there was in all 
the cases a more or less abundant precipitate of albumen, greater when 
the urine was blackish or brown, and less in proportion to its light color. 
This proportion of the coagulum to the blood present in the urine is, 
according to M. Legendre, a fundamental difference between the albu- 
minuria of scarlatina and that in Bright's disease. When the coagulum 
was deposited, the supernatant fluid assumed its natural color, and the 
precipitate appeared either of a brown or ash-gray color, and exhibiting 
under the microscope blood-globules, blanched, but quite recognizable. 

In certain cases, when death occurred from other diseases, M. Legen- 
dre found the kidneys enlarged and less brown than usual ; in some 
parts grayish. Divided lengthwise, it was evident that the increase 

i Hufeland's Journal, Feb. 1824. 

2 Edinburgh Medical and Surgical Journal, 1833. 

3 Some Account of the Epidemic of Scarlatina which prevailed in Dublin from 1834 to 
1842. 



628 SCARLET FEVER. 

depended upon swelling or puffiness of the cortical substance, which 
presented a granular, " sandy or granitic" aspect, which seemed to arise 
from the glands of Malpighi being less colored than the surrounding 
parts. The cortical substance was more easily torn than usual, and was 
somewhat less firm. The tubular substance was unchanged. 

As to the nature of the renal affection, M. Legendre considers that, 
inasmuch as the post-mortem appearances are those of congestion, or 
simple nephritis, and as the coagulation of the urine is explained by the 
presence of blood, which escapes from the uriniferous canals, we are 
not justified in assuming the identity of this disease with that of Bright, 
and that this difference is confirmed by the curability of the one and 
the incurability of the other. 

As to the connection between this condition of the kidneys and the 
scarlatina, he agrees with Guersent and Blache that it is a coincidence, 
or rather that they are two effects produced by the same cause, viz., 
the action of cold during the period of desquamation of scarlatina. 1 

Dr. Graves denies that albuminous urine always results from organic 
disease of the kidneys : he regards it, as does Dr. Blackhall, as merely 
an indication of a peculiar inflammatory condition of the whole system, 
and in this opinion Dr. Lees concurs. 

875. Dr. West has thus described the severe cases of anasarca: 
" The swelling, after having undergone many apparently causeless fluc- 
tuations, becomes extreme as well as universal ; the features are dis- 
figured by dropsy ; the legs greatly swollen, and the abdominal parietes 
much infiltrated, while the skin remains hot and dry. The quantity of 
water voided is very small indeed, and the pain in the back is often 
very severe. The chief suffering, however, is referred to the chest ; 
the respiration is labored and accelerated, and the child is frequently 
unable to resume the recumbent posture, and is, moreover, distressed 
by a frequent short and hacking cough. Under these circumstances 
life is sometimes prolonged for several days, though in a state of ex- 
treme suffering, remedies proving unable either to increase the action 
of the kidneys or to relieve the dropsy. Death is sometimes preceded 
by a sudden aggravation of the signs of disorder of the respiratory 
organs, which assume all the painful characteristics of oedema of the 
lungs ; and in other cases a comatose condition comes on, such as often 
precedes death from Bright's disease in the adult. Sometimes a tem- 
porary improvement takes place, the anasarca abates, and the kidneys 
resume their functions ; but the patient dies not long afterwards, from 
the effects of pleurisy or pericarditis, which had come on almost un- 
noticed during the acute stage of the affection." 

Dr. West does not state exactly what he considers to be the connec- 
tion of the albuminous nephritis with the anasarca, but he has described 
what he believes to be the pathological stages of the former: "The 
microscope has shown us that the morbid process begins in the cortical 
parts of the inflamed kidney, the urinary tubules of which are stimu- 
lated to an increased production of their epithelial lining, or even to a 
pouring out of solid fibrous matter into their cavities. The urine car- 

! Rcchercbes, &c, sur quelques Ma!, de l'Enfance, p. S1G. 



SCARLET FEVER. 629 

ries away with it some of these matters, and thus frees the tubules for 
a time ; but as these contents are reproduced in quantities too large to 
be thus eliminated, some of the tubules become plugged and impervious, 
sometimes even so over-distended that they give way and are completel} 7- 
destroyed. Nor is this all, but the capillaries of the organ necessarily 
bear a part in the mischief. At first, from over-congestion, they be- 
come dilated and varicose, and afterwards (in part, probably, from the 
formation of fibrinous clots within them, in part as the result of a pro- 
cess of adhesive inflammation) they become obstructed and even oblite- 
rated. Supposing this morbid process to have gone on to any consider- 
able extent, the kidney must be left by it permanently and irreparably 
injured, while, even in its slighter degrees, it must for a time seriously 
disturb the functions of the organ. In the earlier stages of the disease, 
the presence of albumen in the urine is in part due to the actual escape 
of blood from the overloaded capillaries of the kidney, and in part to 
the temporary suspension of its functions. If, at a later period, when 
the urine has lost its preternaturally deep color, and has regained much 
of its healthy appearance, albumen should still exist in any quantity, 
there will be reason for apprehending that some abiding injury has been 
inflicted on the organ." 1 

Dr. Copland, in an admirable article, has gone fully into the con- 
sideration of the affections of the kidneys in scarlatina. He believes 
that they are frequently affected in the early stage of the disease, when 
we find more or less oedema or anasarca, or dark-colored eruptions ; the 
urine scanty and high-colored, muddy, brown, or red, from blood mixed 
with it; and further, that from the interruption of the functions of the 
kidneys in the elimination of the excrementitious and unassimilated 
materials in the blood, the mortality in the early stages is probably 
owing to the renal complications: "For I have remarked," he says, 
" in many instances, as respects both the symptoms during life and the 
appearance of the kidneys after death, sufficient evidence to convince 
me that these organs are remarkably congested, and their secreting and 
tubular surfaces are the seats of a similar vascular injection or efflores- 
cence to that existing in the vascular rete of the skin ; and that this 
efflorescence on the surface of the uriniferous tubes, &c, and the asso- 
ciated swelling and congestion of these organs during the early stages 
of the malady, either impede or interrupt, or altogether suppress the 
function of urinary excretion, and thereby occasion an accumulation of 
excrementitial and contaminating materials in the blood, and consecu- 
tively an increase of the poisonous action of the infected blood upon 
the nervous system, and on vital organs and parts, thereby producing 
further complications, &c." 2 

Dr. Copland subsequently notices the affection of the kidneys and 
dropsy, as occurring after scarlatina. The latter he considers as being 
chiefly caused by the former, although the state of the skin may assist ; 
and he alone seems to have noticed what I have no doubt is the case, 
that certain other sequelae of scarlatina are the result of this condition 

1 Diseases of Infancy and Childhood, p. 422. 

2 Diet, of Pract. Med., part xiv. p. 073, 



630 SCARLET FEVER. 

of the kidneys, and of the imperfect performance of their functions, as, 
for example, eifusion into the ventricles of the brain, into the cavities 
of the chest, diffuse inflammation, ansemia, and its consequences, &C. 1 
Thus, then, we find, 1, scanty urine, loaded with lithates and varying 
in color; 2, containing very often blood, which gives it a color of rusty 
iron or porter brown ; 3, containing albumen, which does not depend 
upon the existence of Bright's disease in the kidney, but from a high 
degree of general congestion with inflammation of the tubes ; and 4, 
containing epithelial casts or debris of the same, thrown off from the 
tubes, constituting a true desquamative nephritis, as Dr. Geo. Johnson 
has termed it. 

More recently, Dr. George Johnson has minutely described this affec- 
tion, which he terms "acute desquamative nephritis," and I would 
strongly recommend a perusal of this section of his valuable work. 2 

876. In addition to effusion into the serous cavities, M. Legendre 3 
has investigated, with his usual acuteness and care, a consequence of 
the anasarca which has been very much overlooked — I mean oedema of 
the lungs. This he believes to be dropsy of the interstitial cellular 
membrane of these organs, and not vesicular oedema ; for whereas in 
the latter, the lungs are of a grayish rose color, contain air, crepitate, 
and float in water ; in the former, they are of a lilac color, entirely 
without air, and neither crepitate nor float in water. 

The disease is seldom recognized during life unless extensive, but 
then it gives rise to characteristic symptoms, sometimes commencing by 
cough and some oppression in breathing when it precedes general ana- 
sarca ; after this occurrence the cough and dyspnoea increase greatly, 
and threaten suffocation. When oedema of the lung and general ana- 
sarca set in together, the child is suddenly attacked by cough and dys- 
pnoea, so that it cannot lie down. There may be fever, agitation, and 
gastric disturbance. Generally speaking, there is heard a subcrepitating 
rale, without dulness, except towards the lower part of the chest, but 
the signs are not in proportion to the extent of the mischief. 

The action of the heart is energetic, but the pulse weak and quick, 
from 120 to 160, whilst the respirations amount to 50, 80, or even 100 
per minute. 

Dr. Lees alludes to this complication as causing the oppression of 
breathing in one of his patients. 4 He believes that the fluid may be 
effused either into the cellular substance of the lungs or into the cavity 
of the thorax. 

This is a much more dangerous form of disease than the vesicular 
oedema, both from the impediment which it offers to aeration of the 
blood, and from its occurrence at a time when the child is weakened, 
and is embarrassed by general anasarca. 

The antiphlogistic treatment, so useful for the general dropsy, appears 
equally successful in removing oedema of the lungs. 

877. Now let us see to what our information amounts. We find that 

1 Diet, of Pract. Med., part xiv. pp. 779, 780. 2 Diseases of the Kidney, p. 84. 

s Recherches sur quelques Mai. de l'Enfance, p. 324. 
4 Dub. Journal, vol. xxiii. p. 232. 



SCARLET FEVER. 631 

in some cases, m the early stage, anasarca occurs, and that in these 
cases, and in others where there is no anasarca, the urine is scanty, 
discolored, albuminous, and contains blood- globules ; in other cases, at 
a more advanced period, more extensive and general dropsy occurs, 
accompanied with a certain train of symptoms, and that in these also 
the urine is albuminous and contains red globules ; that this change in 
the urine is owing to congestion or inflammation of the kidney, and seems 
in some way connected with the dropsy, either as cause and effect, or 
as a consequence of the same cause; that the effect of this condition of 
the kidney upon the blood is to deprive it of red globules, to arrest the 
excretion of excrementitious matters and of miasmatic impurities, and, 
as a consequence, to induce certain other complications, 1 and to leave 
the patient exposed to the effects of impure blood, or blood with the 
natural and healthy proportions of its constituent parts destroyed. 

I think we possess sufficient evidence to prove the existence of con- 
gestion or inflammation of the kidneys, but not enough to lead to the 
inference that the albuminuria accompanying scarlatinous anasarca h 
always owing to Bright's disease, nor that this state of the kidney is 
very liable to degenerate into Bright's disease. 

There are only two instances of which I am aware in which abscess 
was the result of scarlatinous nephritis ; both are contained in a paper 
by Dr. Bose Cormack. 2 

878. k. Ophthalmia. — Mild attacks of ophthalmia not unfrequently 
occur during convalescence from scarlatina, but in general they give but 
little trouble, unless the child should be of a scrofulous constitution or 
much worn down. Occasionally, however, the attack is much more 
severe, and may end in sloughing of the cornea, as in the case related 
by Dr. Asbrey "in which, simultaneously with the gangrene of the 
neck, sloughs formed on both corneas, and rapidly extended, involving 
all the other textures of the eyes." 3 Dr. Gregory also alludes to simi- 
lar cases. 4 

I. Otitis. — Inflammation of the ear may occur as an extension of 
the disease of the throat, and may run on into ulceration, involving 
ultimately the "destruction of the small bones of the organ; inflamma- 
tion, ulceration, and perforation of the tympanum ; chronic otitis, with 
offensive discharge; inflammation and ulceration of the membrane lining 
the cochlea and semicircular canals ; caries of the petrous portion or 
mastoid process, or other parts of the temporal bone ; and even the ex- 
tension of inflammation, suppuration, or ulceration to the membranes 
and substances of the brain may supervene ; and, as respects these lat- 
ter changes especially, not unfrequently at remote periods from the 
primary affection of the throat, and extension of lesion to the internal 
ear. When disease of the ear is so far advanced as to implicate the 
bone in which the organ is lodged, the consequences are serious, not 
only as respects the organ itself, but also as regards adjoining vital 

1 On the Dropsy following Scarlet Fever, by Dr. Scott Alison, Lond. Jour, of Med., 
No. iii. p. 227. 

2 London Jour, of Med., No. v. p. 454. s From Clinical Med., vol. i. p. 334. 
4 On Eruptive Fever, p. 128. 



632 SCAKLET FEVER. 

parts, the affection of which often occasions great and protracted suffer- 
ing, and ultimately fatal results." 1 

Otorrhcea is stated to be frequent, but of no importance, by Heyfel- 
der ; it is even regarded as favorable by Berndt, when the nervous sys- 
tem is much affected. Guersent and Blache have rarely met with it. 

m. Hemorrhages. — In addition to blood discharged from the kidneys, 
we occasionally meet with epistaxis occurring in the inflammatory stage 
or towards the end, in cases of angina maligna. Bleeding from the 
throat has also been noticed. Dr. Fothergill mentions that hemorrhage 
from the nose or mouth has sometimes carried off the patient, and a 
similar result has occurred from bleeding from the ear. 2 Dr. Graves 
mentions a case of Mr. Porter's in which hemorrhage from the ear proved 
fatal, and another fatal result from epistaxis. Drs. Hunt and Chas. 
Johnson met with a case of fatal hemorrhage from an ulcer of the throat. 
Drs. Asbrey and Kennedy cited fatal hemorrhage from the vessels des- 
troyed by the sloughing of the neck. 

n. Vaginal Discharges. — At the decline of the eruption of scarlatina 
girls are occasionally though rarely liable to vaginal discharge. Papers 
on this subject have been published by Dr. Barnes 3 and Dr. Rose Cor- 
mack, 4 and in Dr. Miller's late work on scarlatina, he mentions that he 
considers it very rare, as he has not observed it. Dr. Cormack, how- 
ever, frequently met with it in the epidemic of 1848-49. It is a simple 
and very manageable affection ; its only importance being the question 
that may be raised as to its being blennorrhagic; those who know how com- 
mon similar vaginal discharges are among young children will hesitate 
before attributing this character to it. Fomentations with hot water, a 
little black wash, or in obstinate cases, a weak solution of nitrate of sil- 
ver will be sufficient for the cure if convalescence progress favorably. 

o. I think I have noticed at sufficient length all the principal compli- 
cations of scarlatina. There are undoubtedly other sequelaa which 
occasionally occur, as Eberle remarks : "At times the disease gives rise 
to various nervous affections, such as hysteria, spasmodic asthma, chorea, 
epilepsy, and neuralgic pains in the extremities ; and occasionally it has 
been followed by strumous disorders, chronic cutaneous eruptions, herpes, 
gutta serena, and rheumatic pains." 5 

Small ulcers about the nose and at the corners of the mouth, purulent 
discharges from the nostrils, tenderness of the skin, severe pains in the 
limbs, arthritis, and erythematous eruptions are by no means uncommon. 
In the epidemic described by Dr. Kennedy purulent effusion into the joints 
was a favorable sequelae. One or more joints were attacked and filled 
with pus ; the synovial membrane being sometimes healthy, sometimes 
inflamed, coated with lymph, and the cartilages ulcerated. In other 
cases the swelling was caused by lymph effused round the joints. 6 Prof. 
R. Smith has brought similar cases before the Pathological Society, and 
recently I have met with two cases of the kind. 

1 Copland's Diet, of Pract. Med., part xiv. p. 678. 

2 Works, vol. i. p. 376. 3 London Med. Gaz., July 12, 1850. 
4 Ibid., Aug. 2. . 6 Diseases of Childreu, p. 454. 

6 On Scarlatina,^ 22. 



SCARLET FEVER. 633 

Dr. Armstrong has noticed that the hair is very apt to fall out after 
scarlatina, and to be very imperfectly reproduced. 

Dr. Huxham mentions "excoriation of the anus and buttocks;" and 
Dr. Graves relates a case in which aphthous ulceration of the anus 
occurred. 1 

879. Pathology. — The appearances found after death, dependent 
upon scarlatina, but not resulting from the complications, are neither 
many nor of great magnitude. The eruption, if previously faint, may 
have disappeared from the surface of the body, or it may remain in 
patches of a livid hue, and, on dividing the skin, the vascular network 
is found unusually injected. 

The redness of the mouth, tonsils, and pharynx disappears when the 
attack has been slight, or when fatal in the early stage; but in severe 
cases the mucous membrane may be found softened, ulcerated, or 
gangrenous. 

The digestive mucous membrane is softened in the malignant cases. 
Brunner's and Peyer's glands are enlarged, and occasionally the mesen- 
teric glands. 

Congestion of the brain, or its membranes, of the liver, of the spleen, 
and of the kidneys, is by no means unusual, according to Killiet and 
Barthez. 

880. Each complication will, of course, furnish its peculiar morbid 
lesion, but it would be a waste of time to repeat them here. There 
are two or three points, however, on which it is desirable to add a few 
words. 

Rilliet and Barthez consider the essential element of the disease — 
the point du depart — to be the condition of the blood ; and they describe 
it as varying in its state, sometimes being liquid and unusually fluid, 
black, or serous, and clear, with few clots, and those soft and easily 
crushed; in other cases the coagula were abundant, firm, solid, and in 
part fibrinous. Sometimes it was effused profusely into the tissues, in 
other cases the congestion was normal. Occasionally certain organs 
were pale, and contained little blood. 

Andral, Gavarret, and Lecanu analyzed the blood of persons in scar- 
latina, but the result did not differ much from that of healthy individ- 
uals. Dr. Copland speaks of the blood in the malignant form of the 
disease being in the same state as in other malignant fevers. 

881. Again, as the changes in the urine are so important in their 
practical bearing, I will just repeat the principal ones. During the 
early stages of the disease it is always scanty, high-colored, and some- 
times of a deep red hue. In the mild and inflammatory forms it has 
generally an acid reaction, but in the asthenic or malignant scarlatina 
it is either neutral or alkaline, and very turbid, sometimes albuminous, 
and containing blood-globules. In most cases, even early in the dis- 
ease, it rapidly becomes ammoniacal; and in the malignant cases it de- 
posits a viscid, whitish sediment, consisting of the earthy phosphates 
and mucus, and containing urate of ammonia and uric acid. 

" During the advanced stages of the mild and more sthenic form of 

1 Clin. Med., vol. i. p. 341. 



634 SCARLET FEVER. 

scarlatina, the urine becomes more abundant, of greater specific gravity 
from the abundance of saline matters, and present the characters usu- 
ally observed during the decline of inflammatory or continued fevers. 
In asthenic, septic, or malignant cases, the urine becomes, with the pro- 
gress of the malady, of a dark brown or yellowish color, is very scanty, 
and of a specific gravity varying from 1020 to 1025. It has an alka- 
line reaction, with a disagreeable ammoniacal odor, and it occasionally 
contains blood and mucus, or partially dissolved hsematoglobulin, either 
diffused or in llocculent deposits, but rarely any or much albumen. It 
throws down a dirty white sediment, consisting of earthy phosphates, 
urate of ammonia, urate of soda, and mucus, with other animal matters. 
In these cases particularly, and less rapidly in others, the urine becomes 
more decidedly ammoniacal and offensive." 1 

During the process of desquamation the condition of the urine is a 
matter of dispute; some have found albuminuria with dropsical symp- 
toms or without, or dropsy with albuminuria. Solon found albumen in 
the urine of twenty-two out of twenty-three cases of scarlatina; but 
Phillipp, of Berlin, observed at least sixty cases in which there was no 
albumen. It is probable that in very mild cases there is little or no 
albumen, but when fever is excited at this period, and anasarca super- 
venes, the urine generally becomes albuminous; and when this occurs, 
we may expect that certain organic complications, to which I have be- 
fore alluded, will take place. 

When during its early or advanced stage scarlatina is complicated 
with cerebral, pulmonary, or abdominal disease, the urine may either 
be suppressed altogether, or scanty, high-colored, bloody, and albu- 
minous. 

As regards the actual condition of the kidneys in the nephritis con- 
sequent upon scarlatina, in addition to the notice I have already given 
I may quote the description of Dr. G. Johnson: "The kidney," he says, 
"in these cases, is enlarged apparently by the deposit of a white mate- 
rial in the cortical substance; the vessels in the cortical portion, where 
they are not compressed by this new material, are injected, and of a 
bright red hue; the medullary cones are of a dark red color, in conse- 
quence of the large red veins which occupy these portions of the gland 
being distended with blood. The appearance of the entire organ is 
quite that of a part in a state of acute inflammation. When the kid- 
ney has been in a softened condition before the occurrence of the in- 
flammatory disease, as often happens in elderly persons, the lobules on 
the surface appear larger and coarser than natural; the veins, being 
less compressed than when the natural texture of the kidney is firmer 
and more unyielding, are much distended with blood, so that the entire 
organ is of a dark slate color. On a microscopical examination the con- 
voluted tubes are seen filled, in different degrees, with nucleated cells, 
differing in no essential character from those which line the tubes of 
the healthy gland. The Malpighian bodies are for the most part trans- 
parent and healthy, but the vessels of the tuft are sometimes rendered 
opaque by an accumulation of small cells on their surface. Some of 

1 Copland's Diet, of Tract. Med., part siv. p. 681. 



SCARLET FEVER. 635 

the tubes contain blood, which has doubtless escaped from the gorged 
Malpighian vessels. There is no deposit exterior to the tubes." 1 

882. As scarlatina may occur in the course of other diseases, it be- 
comes a matter of practical importance to ascertain what effect is thus 
produced upon the primary affection. 

Any affection of the mucous membrane of the mouth, pharynx, or 
digestive system, but especially the former, appears much aggravated 
by the incursion of scarlatina, which is what we might perhaps have 
anticipated. Trifling disorders become serious, and death may be the 
consequence. 

On the contrary, pulmonary inflammation seems rather benefited than 
injured. Rilliet and Barthez state that they have many times seen scar- 
latina supervene upon pneumonia, and that, unlike measles, it never 
exasperated the pulmonary disease: nay, in one case a slight pneumo- 
nia appeared to be cured by the eruptive fever alone. 

Hooping-cough may be cut short, and chorea disappear, on the ap- 
pearance of scarlatina. 

As to the influence of scarlatina upon tubercles, Rilliet and Barthez 
give the following conclusions as the result of their experience: " 1. 
That scarlatina rarely gives rise to tubercles. 2. That tuberculous 
children rarely take scarlatina, and when they do it is anomalous. 3. 
Children cured of tubercles are more liable to scarlatina than the pre- 
ceding, and the eruption may be normal. 4. Those tuberculous children 
who do take scarlatina have but few crude tubercles, and very rarely 
any that are softened. 5. In these cases, the tubercles have a tendency 
to become cretaceous in a short time." 2 

883. Causes. — Among the predisposing causes, we may mention age, 
children being more frequently subjects of the disease than adults, and 
adults than old people. I have already stated that I do not believe 
that children are more liable, but that they are exposed to the infection 
whilst children, and therefore take the disease before they grow up. 

Infants at the breast often escape the disease, although other mem- 
bers of the family may be suffering from it, probably because they are 
kept more apart from the room where the infection exists ; and we occa- 
sionally see a child enjoying a perfect immunity, even though associating 
with those affected. 

The foetus in utero may have the disease. Cases of this kind are 
collected by Grsetzer, and Dr. Gregory mentions that a child of his own 
was born with it. 

Sex appears to exert no influence, males and females being equally 
liable. In London, in 1838, 747 males and 777 females died of it; in 
1839, 1241 males and 1258 females ; and throughout England and 
Wales, in 1840, 8927 males and 8935 females. 

Of 158 fatal cases, in 1839, in New York, 86 were males and 72 
females; and of 391, in 1840, 208 were males. 

Reid, Richter, and Steiglitz, however, believe that females are more 
liable to it than males. 

1 Cyclop, of Anatomy and Physiology, Art. Ren. 

2 Mai. des Enfans, vol. ii. p. 634. 



636 SCARLET FEVER. 

Scarlatina seems to be more prevalent in temperate climates ; and it 
is more severe and propagated more extensively in warm, humid weather, 
and in low, marshy districts, and in the crowded, dirty, ill-ventilated 
portions of cities. Dr. Gregory mentions that Dr. Jackson could not 
recollect any cases deserving the name of scarlatina in India. Dr. Cop- 
land never met with a case between the tropics. It was introduced into 
North America in 1735, and its progress was slow but fatal. 

It is as yet, I believe, unknown in New Zealand, as it was until lately 
in Australia. In the year 1848, however, it prevailed at Sydney, as I 
am informed by Dr. Silver, late military and colonial medical officer, 
now of Gala, Co. Galway ; and Mr. Gryles informs me that cases oc- 
curred before this time. He is not aware of any other part of that 
continent having been visited by the disease. 

884. The two principal modes of its communication are contagion or 
infection, and by the occurrence of an epidemic of the disease. 

Although the contagious nature of scarlatina has been doubted by 
Dewees, Daehere, Reich, Tortual, and others, yet so many and such 
conclusive facts daily occur that few of the present day hold this opinion; 
and whatever doubt did exist must have been removed by the experi- 
ments of Sir B. Harwood, who succeeded in producing the disease by 
inoculation with the fluid from the vesicles which were intermingled with 
the eruption of scarlatina, although he was disappointed in producing a 
milder disease. 

Dr. Copland met with a case in which the disease was excited by the 
contact of a small quantity of the discharge from the throat of a person 
affected with the malignant anginous scarlatina. 

M. Miquel de l'Amboise succeeded in inoculation by means of the 
blood of a patient in scarlatina. 

The poison of scarlatina, by which it is communicated, consists in 
some miasma, of whose nature we are ignorant, either preserved and 
perpetuated by individual cases, or by fomites, or formed, de novo, at 
different epochs. That it does emanate from persons laboring under 
the disease, and that the atmosphere of certain localities may become 
so impregnated with it as to communicate the disease to individuals 
visiting such places, we have sufficient proof; but it is very difficult to 
say whether the disease may originate spontaneously by any combination 
of predisposing causes. The best writers think not, and it seems to me 
unlikely. 

The media by which the disease is transmitted, in addition to per- 
sonal contact, are the atmosphere surrounding the sick, or substances 
impregnated with the miasma from the sick. The distance to which 
infection may be carried, and the duration of the infecting power pos- 
sessed by fomites, is very uncertain, and will be much modified by the 
freedom of access or exposure to pure air. Infection, as Dr. Sims has 
observed, may remain in a house some weeks, and it certainly may be 
transmitted in clothes to a considerable distance. 

But an important question arises — granted that a person visiting a 
locality where it has prevailed, or using clothes of a patient, may take 
it, can a third person not having the disease carry it from a person who 
has it to others who have not ? I should not like to speak positively, 



SCARLET FEVER. 637 

but during the late epidemic in Dublin, I saw one instance which it 
seemed difficult to explain in any other way. 

Cazenave considers that the greatest activity of the contagion is dur- 
ing the desquamation. 

885. But the extent and desolating fatality are more striking when 
we contemplate its spread as an epidemic. Many examples are on 
record, indeed they are so frequent that it would be impossible to 
attempt an accurate enumeration of them. I may, however, mention 
some of the principal. 

An epidemic angina, with scarlet eruption, raged in Spain in 1610, 
from whence it passed to Naples in 1618. Laurent mentions an epi- 
demic in Germany in 1625, and Sydenham one in London in 1670 and 
1675. Morton described that in London in 1689, and Sir Robert Sib- 
bald that in Edinburgh in 1680. It prevailed in Saxony in 1695. An 
epidemic, which Mr. Wilde thinks was scarlatina, is mentioned by Dr. 
Rutty as prevailing in different parts of Ireland in 1743, 1744, and 
again in 1758, 1759, 1762, 1798, 1799, and 1800. 

It first appeared in Boston, IT. S., in 1735-36 ; it is stated that 
4,000 were attacked, and one in 35 died. In Baltimore it was epi- 
demic in 1847-8. 

Dr. Fothergill has given us the history of the London epidemic of 
1747, 1748. It prevailed at La Haye in 1748, 1749 ; at Upsal in 1741 
(Rosen) ; in Champagne in 1751; at Vienna in 1759 (Stark), and 1770, 
1771, (De Haen, Kirchvogel) ; in the city of Cephalonia in 1763 (Zu- 
latti) ; at Essen in 1763 (Franck); at Harcourt in 1744 (La Pecq. de 
la Cloture) ; at Heidelberg in 1775 (Zimmermann) ; at Copenhagen in 
1777, and again in 1786 ; at Jersey and in New England in 1784 ; at 
St. Christopher's, West Indies, in 1787 (Stephens) ; at Langres in 
1800 ; in Dublin in 1801, 1802, 1803, 1804, 1807 ; and at Caithness, 
in Scotland, and near Brignoles, in France, in 1807 ; at Marseilles in 
1821, 1822 ; in Dublin from 1832 to 1834 (Graves) ; in Virginia, United 
States, in 1832 ; in England in 1838, 1839, 1840 (Gregory) ; in Dublin 
in 1840 (Lees); and in Philadelphia in 1841, 1842 (Meigs). Dr. 
Graves states that it has raged every winter and spring, with undi- 
minished violence, in Ireland, from 1835 to 1846, resisting every kind 
of treatment, but that in 1847, 1848 it had become milder and less 
frequent. 

During the years 1841, 1842, Dr. Meigs states that it prevailed very 
extensively, and was very fatal in Philadelphia. 1 

In the year 1842 it occurred at Market Hill, an account of which 
has been given by Dr. Lynn. 2 

886. Diagnosis. — The characteristic symptoms of scarlatina are, 
violent preliminary fever, with sore throat, followed by the appearance 
of a general rash of an intensely red color, not elevated, and with dis- 
turbance of the renal functions. 

1. It may be distinguished from ulcerated sore throat, by the occur- 
rence of the rash, but when that is absent, as in scarlatina sine exan- 

1 Diseases of Children, p. 448. 

2 Appendix to Dr. H. Kennedy's work on Scarlatina. 



638 SCARLET FEVER. 

themate, the distinction will be very difficult, if not impossible, unless 
scarlatina have attacked other members of the same family. 

2. From measles by the greater intensity and shorter duration of the 
initiatory fever, the sore throat, the absence of catarrhal symptoms, and 
the general and equable appearance of the rash, instead of the semicir- 
cular or crescentic form and elevated surface of the eruption of measles. 
The presence of albumen and blood in the urine, and the occurrence of 
dropsy at a more advanced period, will be an additional evidence that 
the disease is scarlatina. 

3. From roseola. The eruption in this disease is sometimes an ad- 
mirable imitation of scarlatina, but in general there is much less fever, 
no sore throat, and the disease lasts a much shorter time. 

4. From miliary fever. In this disease there is an eruption of small, 
hard vesicles, containing clear water, as though water had been 
sprinkled in very minute drops, resembling in appearance and touch 
the drops on an ice plant, sometimes on a flushed surface, but there are 
few, if any, catarrhal symptoms, no sore throat, and subsequently no 
desquamation. In scarlatina the florid redness is general and equable, 
and if any miliary vesicles are seen they are comparatively few ; and 
the sore throat, intense fever, disordered urine, and desquamation, will 
sufficiently prove the nature of the disease. 

5. But suppose the patient has the disease very lightly, the eruption 
fainter than usual, and no sore throat : in such cases it is often impos- 
sible at once to say whether the disease be scarlatina or not. There 
are three circumstances, however, any one of which may clear away all 
doubt. 1st, the desquamation of the cuticle in large flakes, which is so 
unlike the small, scaly or powdery desquamation of measles. 2d, other 
children of the same family catching the disease, and exhibiting its 
peculiar characteristics; and 3d, the occurrence of the distinctive se- 
quelae, anasarca with albuminous urine, &c. 

887. Prognosis. — As a general rule, scarlatina is a more serious 
malady with children in proportion as they are young ; infants under 
two years suffering more from it than after that age. 

But in mild cases there is little danger, if care be taken that the child 
do not take cold during the latter stages and convalescence. 

In scarlatina anginosa, when the inflammatory symptoms run high, 
where the throat is much affected, when internal organs are attacked, 
or when nephritis exists, the disease often proves very fatal. 

Scarlatina maligna is as fatal a disease as any to which children are 
liable ; the typhoid character of the fever, the disposition of the sore 
throat to become gangrenous, the internal inflammations, and the renal 
complications, render it extremely difficult to treat the case satisfac- 
torily. 

The occurrence of an epidemic, and its peculiar character, must be 
taken into consideration in forming our prognosis. I have already 
shown the fearful increase of mortality in London in certain epidemics. 
They sweep down whole families occasionally, and during their preva- 
lence, even cases that commence mildly are by no means to be regarded 
as safe. 



SCARLET FEVER. 639 

The mortality has varied from 1 in 6 to 1 in 40, according to the 
character of the epidemic. 

888. Treatment. — As a preliminary to the successful treatment of 
scarlatina, as of other epidemic diseases, the physician ought to be fully 
acquainted with the prevailing atmospheric constitution of disease, and 
of the type of the peculiar epidemic, as this knowledge alone will often 
determine, beforehand, whether antiphlogistics or stimulants, whether 
depletives, or tonics, are to be employed. That the importance of this 
may be more fully understood, I would recommend strongly, the 
perusal of Dr. Graves' 22d Lecture "on scarlatina," which is worthy 
of the pen of that distinguished physician. Moreover, it will be neces- 
sary also to understand the constitutional peculiarities of the patients. 
I have seen cases, and so I am sure have others, in which it was neces- 
sary to use stimulants very freely from the beginning, and throughout 
the disease. I have a strong notion that Dr. Stokes' observations on 
the condition of the heart in typhus fever as an indication for wine, 
apply also to the typhoid form of scarlatina. 1. Mild cases of scarla- 
tina, when the fever is slight, the sore throat trifling, and the eruption 
favorable, require but little treatment beyond a dose of aperient medi- 
cine, a demulcent gargle, and a cool, well ventilated apartment. 

If there be much fever, the pulse quick, skin hot, urine scanty, with 
pain in the back and limbs, an emetic will afford great relief, and its 
action should be promoted by diluent drinks, and subsequently by dia- 
phoretics. 

When the head is much affected in the preliminary stage, Dr. Arm- 
strong recommends the warm bath, strongly impregnated with salt, 
followed by a brisk purgative. 

The bowels must be kept free, and the surface not too much heated 
by bedclothes. 

II. Scarlatina anginosa will require a more active treatment. In 
the more sthenic form we should commence with an emetic, nor will 
this be less "beneficial if vomiting should have occurred ; if there be 
pains in the back and scarcity of urine. 

If the pulse be full and quick, and there be much cerebral excite- 
ment, or pain in the region of the kidneys, with scanty and high-colored 
urine, it will be advisable to take some blood by cupping or leeches 
from the nape of the neck, behind the ears, or from the loins. 

Drs. Macintosh, Armstrong, and others, recommend general blood- 
letting in the early stage, and speak most highly of its beneficial effects 
in reducing the fever; but the more general opinion, in which I fully 
agree, is, that it is not ordinarily necessary, that it requires great dis- 
crimination in its use, and that it is mainly beneficial in cases where 
there is high fever, a full pulse, and a disposition to inflammation of 
some internal organ. In some epidemics it is borne very well, in others 
its effects are very pernicious. 

Whether cupping be necessary or not, the sore throat will be bene- 
fitted by the use of a stimulating liniment, but we must take care that 
the skin be not too much irritated. Blisters are rarely, if ever advis- 
ahle, on account of their disposition, in scarlatina, to run on into severe 
ulceration. 



640 SCARLET FEVER. 

Or the throat may be carefully fomented, or a poultice applied exter- 
nally, and the steam of hot water inhaled. 

Cooling gargles, if the child be old enough to use them, will be found 
very soothing. They may be made of infusion of roses or cinchona, 
red wine and water, camphor, or rose-water with nitrate of potass, &c. 

After the vomiting has ceased, a few grains of calomel may be placed 
on the child's tongue, to be followed in an hour by some gentle purga- 
tive of rhubarb and magnesia, infusion of roses, or senna, with manna 
and salts, or castor oil, &c, so as to evacuate the bowels completely. 

Saline, diaphoretic, or diuretic mixtures may then be given, in a state 
of effervescence or not, as the patient pleases, although Dr. Bateman 
doubts the success of the former, unless the heat of the skin have been 
previously reduced. Richter recommends the muriate of ammonia, and 
Steiglitz dilute sulphuric acid. 

When the heat of skin is great, Dr. Currie and others advise cold 
affusion, but it would seem that it has been too indiscriminately used, 
and disappointed expectation. It is not without danger, except in the 
more sthenic cases, as it rather favors internal complications. 

Dr. Bateman observes: "We are possessed of no physical agent, so 
far as my experience has taught me (not excepting even the use of 
bloodletting in inflammation), by which the functions of the animal 
economy are controlled with so much certainty, safety, and prompti- 
tude, as the application of cold water to the skin under the augmented 
heat of scarlatina and of some other fevers." I have had the satisfac- 
tion, in numerous instances, of witnessing the immediate improvement 
of the symptoms, and the rapid change in the countenance of the patient, 
produced by washing the skin. Invariably, in the course of a few 
minutes, the pulse has been diminished in frequency, the thirst has 
abated, the tongue has become moist, a general free perspiration has 
broken forth, the skin has become soft and cool, and the eyes have 
brightened; and these indications of relief have been followed by a calm 
and refreshing sleep." 1 

Dr. Armstrong speaks highly of tepid affusion four or five times in 
twenty-four hours, in the mildest form, and of cold affusion during the 
first three days, in scarlatina anginosa. 

Dr. Copland derived so little benefit from affusion that he prefers a 
tepid bath, or cold or tepid sponging of the surface. Dr. Dewees thinks 
the sponging as effectual and safer than affusion. 

Some modification is necessary in the asthenic form of anginose scar- 
latina. General bloodletting is out of the question, and even local 
cupping or leeching seems to do more mischief, by weakening and de- 
pressing the patient, than good. We should commence with an emetic, 
followed by purgatives and diaphoretics, and have recourse to stimu- 
lating liniments to the neck and loins, if necessary. 

If the urine be scanty, we must give some diuretic, as the acetate of 
ammonia, or sweet spirits of nitre, or nitrate of potash, internally. 

So far I have supposed the case to be uncomplicated, and these 
means, wisely used, may succeed in preventing complications in many 

1 On Cutaneous Diseases, p. 81. 



SCARLET FEVER. 641 

cases. In others they will fail, or some complication may have occurred 
before we were called to the patient, and our duty will be to treat each 
complication according to the rules laid down for the disease, bearing 
in mind the distinctive individual or epidemic character of the scarla- 
tina, and modifying our treatment accordingly. Leeches to the part 
affected, fomentations, embrocations, poultices, &c, may be used gene- 
rally with benefit. 

III. In scarlatina maligna our treatment must vary ; moreover it 
must be very prompt, or we may lose our patient, on account of the 
rapidity of the disease. 

When it commences with high fever, full, quick pulse, Dr. Armstrong 
advises cold affusion, and if that fail in reducing the heat, he recom- 
mends bleeding. This, however, will rarely be necessary or justifiable. 

Even local bloodletting, which seems called for by the symptoms, is 
rarely of any use, and may be injurious, either by weakening the pa- 
tient, or from diffuse inflammation attacking the leech-bites, and spread- 
ing to the neighboring parts. 

An emetic may be given immediately, with an ample supply of dilu- 
ents, and a mercurial purgative; and the liniment, or a turpentine em- 
brocation applied to the neck or loins, or both. 

But more than this must be attempted. The decoction of cinchona 
should be given every three or four hours, with the carbonates of soda, 
potash, or ammonia, either in a state of effervescence, the alkaline 
being in excess, or with the alkaline carbonate only. If the acid be 
omitted, the fixed and volatile alkalies may be given at the same time, 
with the spiritus setheris nitr., and tincture of serpentaria. 

"It is often difficult," Dr. Copland observes, "to determine whether 
or not the decoction should be given with an acid or an alkali, in the 
more malignant states of scarlatina. The choice should depend, in some 
measure, on the state of the urine. If this secretion be not suppressed, 
and if it be alkaline, and contain phosphates, the cinchona should be 
conjoined with hydrochloric acid and hydrochloric ether ; or the sulphate 
of quinia may be given in the infusion of roses, with dilute sulphuric 
acid and sulphuric ether, or the compound spirits of ether. When, how- 
ever, the urine is suppressed, or nearly so, and when it presents an acid 
reaction, or is albuminous or bloody, after having recourse to emetics 
and terebinthinate epithems over the loins, I have generally preferred 
a combination of the decoction of cinchona, with the liquor ammonise 
acetatis, or carbonate of ammonia, or with either of the alkalies, in a 
state of effervescence with a vegetable acid. 1 

At the same time, bark should not be given without discrimination. 
Dr. Armstrong regards stimulating and tonic remedies as " pernicious 
in the first stage, and most destructive in the second;" and so they may 
be, if inflammatory symptoms run high : but after these have been sub- 
dued, and the disease shows itself in its true form, then assuredly tonics 
are beneficial. 

Dr. Garnett formerly recommended the chlorate of potass, and Dr. 

1 Diet, of Pract. Med., part xiv. p. 693. 

41 



642 SCARLET FEVER. 

Clutton the hydrochloric ether, with or without decoction of bark, in 
malignant scarlatina. 

Dr. Peat and Dr. Stewart speak most highly of the sesquicarbonate 
of ammonia, as a stimulant, in doses of from two to four grains, in an 
emulsion with mucilage, for children from four to seven years of age. 

Infusion of serpentaria is useful from its being both a stimulant and 
a diaphoretic. 

Capsicum was recommended by Dr. Stevens as a powerful stimulant, 
and experience proves it to be of great value. He tried it in about four 
hundred cases with great success. 

If the symptoms be not ameliorated, the emetic must be repeated, and 
the other remedies continued. 

Chlorine and the chlorides have been strongly recommended in the 
severe cases. 

Powdered carbon alone, or in combination with quinine, cascarilla, or 
cinnamon, with the addition of camphor, creasote, and capsicum, have 
been beneficially employed by Dr. Copland. 

The flowers of arnica are recommended by Malfatte and Steiglitz. 
Reil speaks highly of large doses of musk when there is much restless- 
ness and nervous irritation. 

Dr. Schneemann, of Hanover, has strongly recommended the inunction, 
morning and evening, of the outer surface (except the face and scalp) 
with fat of bacon, so that the body is to be coated with fat. This may 
be done at the commencement of the eruption and continued until des- 
quamation is complete. Various are the good effects said to result; the 
prevention of cold, relief of the itching and brittleness of the skin, pro- 
motion of its functions, and of the oxidation of the blood ; preventing 
infection and diminishing infection, &c. Of course this does not super- 
sede more active treatment if necessary. 

The local applications to the throat are are of various kinds. Exter- 
nally the liniment or the turpentine should be applied, as in the former 
variety, and internally, if the child be old enough to gargle, it may 
use a gargle of alum and water, port wine and water, chloride of lime 
and water, decoction of bark, with nitric acid, and infusion of cayenne. 

Dr. Willan recommends fumigation with nitrous acid gas. 

Dr. Jackson applies iced water, or ice in a muslin bag, to the back 
part of the mouth. Dr. Eberle has found benefit from an infusion of 
the indigo plant, and from black wash. 

If not able to use a gargle, it must be applied with a sponge, or a 
dossil of lint on the end of a rod, three or four times a day. 

If the ulceration of the throat assume a grave character, we must 
have recourse to stronger caustics, and after cleansing the parts, apply 
nitric acid or nitrate of silver freely, so as to check its progress by 
changing its character, as I recommended when speaking of putrid sore 
throat. 

The bowels must be kept moderately free, and it seems generally 
agreed that calomel acts most beneficially in this way ; it may be aided 
by castor oil, rhubarb, jalap, or a saline mixture. It will be necessary 
to be careful in giving purgatives during the collapse, as it may thereby 
be increased. 



SCARLET FEVER. 643 

Cool drinks should be permitted. Cold water, iced water, or water 
acidulated with lemon-juice, dilute sulphuric or muriatic acids, is exceed- 
ingly grateful and refreshing. 

In addition to the tonic and antiseptic remedies already mentioned, 
it will be necessary, in many cases, to give wine or brandy freely, and 
such nutriment, by broth, beef-tea, &c, as the patient can take. 

The treatment I have thus shortly sketched will generally be suffi- 
cient for each variety, but it must be modified according to the consti- 
tution of the child, the character of the epidemic, and any complication 
that may exist. 

Of the suitable treatment for the latter I have already spoken in the 
chapters treating of those diseases, to which I must refer the reader, 
but on the treatment of the renal affection I must say a few words here. 

889. Something may be done in the way of prevention during the 
period of desquamation, by carefully avoiding cold, prohibiting the too 
free use of animal food and stimulating beverages, and by promoting the 
healthy action of the skin by warm clothing, warm baths, &c. 

But when the disorder actually exists, antiphlogistic remedies and 
diet must be adopted, unless the strength of the child be much reduced, 
or the type of the scarlatina be typhoid. Bleeding, cupping the loins, 
or a few leeches, will generally afford relief, and it may be repeated if 
necessary, and if the child can bear it. 

If the weakness be too great, we must content ourselves with apply- 
ing a blister to the loins, if the scarlatina have subsided; or a liniment 
of oil and turpentine, or the compound camphor liniment, and the occa- 
sional use of the warm bath. 

Internally, diaphoretics should be administered and gentle purgatives. 

Dr. West speaks highly of tartar emetic, in nauseating doses, given 
every three or four hours, combined with a solution of the acetate of 
ammonia; and afterwards mild diuretics, as the acetate of potash, ex- 
tract of taraxacum, spirits of nitrous ether, &c. 

I have seen the amount of blood in the urine checked by the use of 
gallic acid in doses of one-third or one-half of a grain three times a day. 

The disappearance of the blood and albumen, and the resumption of 
its healthy color by the urine, will be the best evidence of the diminu- 
tion of the renal disease. 

Fortunately the treatment I have advised for the affection of the 
kidneys is equally calculated to benefit the anasarca connected with it, 
which supervenes during the period of desquamation or convalescence. 

General bleeding, if the pulse be full and the child strong, as advised 
by Sydenham, Richter, and others, or cupping or leeching with dia- 
phoretics, diuretics, and baths, are the remedies upon which we must 
chiefly rely; but I am anxious to recommend the vapor bath especially, 
from the great benefit I have seen derived from it. It may be easily 
administered without the usual expensive apparatus. Take a cane- 
bottomed chair, suspend a pan of hot water underneath, near to the 
floor, and place under it a spirit lamp, and then cover the seat and legs 
of the chair with a blanket, so as to prevent the hot steam from scald- 
ing the child; then place the child, naked, upon the seat, and envelope 
the chair and the child (except his head) in a blanket. 

In a few minutes the child will have a comfortable and complete 



644 SCARLET FEVER. 

vapor bath, which is far less exhausting than a common warm bath, 
and has a more beneficial effect upon the anasarca. 

When, after the nearly complete disappearance of the oedema, and 
the return of the urine almost or altogether to a healthy state, the child 
still continues pale, and languid, and feeble, the tincture of the sesqui- 
chloride of iron is the best tonic that can be administered, and under 
its use any traces of albumen that previously existed in the urine will 
be altogether removed. 1 

890. The diet of the child during the simple and anginose scarlatina 
should be restricted, and of a bland character ; in angina maligna we 
may have to give broths, beef-tea, jelly, or even wine and brandy. 

I would wish, in this edition, to express even more strongly than in 
the former one, the necessity which exists for a moderate and bland 
diet, during convalescence, especially where there is any tendency to 
anasarca. By a stimulating diet, any febrile action is kept up, and the 
stomach and bowels become disturbed. Milk, farinaceous food of any 
kind, and occasionally a little weak broth, will be sufficient for a week 
or two, after which the diet may be increased, and if tonics be deemed 
necessary, I am inclined to think a weak decoction of bark is better 
than wine. 

During the height of the disease the child should be moderately 
covered with clothes, the room be kept cool and well ventilated. 

We must remember that during convalescence the sequelae of the dis- 
ease arise, and therefore great care should be taken that the child be 
warmly clothed and not exposed to cold or damp. 

Even when convalescence seems going on satisfactorily, I would re- 
commend that the child should be confined to the house for two or three 
weeks. I have repeatedly seen children, who appeared perfectly well, 
allowed to go out with due precautions, who yet caught cold, and were 
attacked by some of the sequelae of scarlatina. 

891. Prophylactic Treatment. — Many plans have been suggested for 
preserving individuals from scarlatina. Dr. Withering recommends the 
frequent expectoration of the mucus that collects upon the mucous mem- 
brane of the fauces and nose, and that when the infection has been im- 
bibed, the person should take an emetic, wash the mouth with soap-leys 
diluted with water, and promote sneezing, then go to bed and take wine 
whey with spirits of hartshorn. He advises that when a family or 
school is attacked the members should not be dispersed, but, "allotting 
apartments on separate floors to the sick and healthy, choosing for 
nurses the older parts of the family, or those who had already had the 
disease, and prohibiting any more communication between the sick or 
their attendants and the healthy, with positive orders to plunge into 
water all the linen, &c. used in the sick chambers, have universally 
been found sufficient to check the further progress of the infection. 

Dr. Sims thinks the best precaution to be to take so much rhubarb 
every morning as will produce a loose motion in the day. Dr. Williams 
thinks this precaution as effectual as that of Hahnemann, if not much 
more so. 

1 West, Diseases of Infancy and Childhood, p. 434. 



VARICELLA. 645 

Belladonna. — Hahnemann recommended a minute portion of bel- 
ladonna to be taken twice a day. Ettmuller, Berndt, Korrf, and 
Hufeland believe in its good effects. Salzer and others have found it 
useless; and Hildenbrand and others treat it with ridicule. 

Dr. Stievenart of Valenciennes tried it upon 200 individuals during 
an epidemic of scarlatina near Valenciennes, and all escaped the disease. 

"In an epidemic which occurred in South Carolina Dr. Irwin made 
a very extensive trial of the prophylactic properties of belladonna. 
Three grains of the extract was dissolved in one ounce of cinnamon 
water, and two or three drops of the solution were given morning and 
night to a child under one year old, and one drop more for every year 
above that age. Of 250 children who took the belladonna, less than 
half a dozen had the disease, and but very mildly. After eight or ten 
days' use of the medicine there occurred an eruption over most of the 
surface, in some cases profuse and troublesome from itching. Those 
families who did not take the preparation had the disease with scarce 
an exception." 1 Dr. M'Kee made a similar trial with success. Dr. 
Condie found it of no use. Guersent and Blache, Rilliet and Barthez, 
think it deserving of further trial. 

Dr. Sneeman dissolves gr. iij. in an ounce of water, and gives to the 
child the number of drops + 3 that it is years old. 

My friend, Mr. Tuffnell, has mentioned to me two trials that he made 
of it. In the first, scarlatina of a very malignant form broke out in an 
establishment where there were 29 children of different ages who had not 
previously had the disease. Ten were attacked and the remainder put 
under the influence of belladonna, not one of whom contracted the dis- 
ease. On the other hand, in a family of children, five of whom had not 
had scarlatina, the eldest being attacked, the others took belladonna, 
but all successively sickened and had the disease more severely than 
the first. 

Calomel has been recommended by Kreysig and Selig; Theussink, 
calomel and the golden sulphuret of antimony; Eichel, emetics, followed 
by diaphoretics. Others have recommended the mercurial acids, or 
capsicum, quinine, camphor, &c. 

Whether there be any special prophylactic or not, I cannot say. I 
am sure that good food, fresh air, exercise, ventilation, cleanliness, &c, 
by promoting the health, may either preserve from the disease, or will 
tend to diminish its severity. 



CHAPTER III. 

VARICELLA. — CHICKEN-POX. — SWINE- POX. 

892. This is a trifling disorder, hardly worthy of the name of an 
eruptive fever. It was confounded with smallpox until Dr. Heberdea 

1 Condie on Diseases of Children, p. 441. 



64:6 VARICELLA. 

published his Memoir, 1 and ever since there have been controversies as 
to whether or not it is not a modified variola. Valuable descriptions 
have been given by Frank of Vienna, Willan, Heim, Mohl, Thompson, 
Gregory, &c. 

Dr. Gregory defines the disease as " a slight disorder, the offspring 
of a specific miasm, which, without irritating fever, throws out an 
eruption of confluent vesicles, which mature in three days,and desiccate 
into granular scabs, which speedily fall off. Little or no fever accom- 
panies the matured stage, and no secondary fever follows. The disorder 
chiefly prevails among children, and occurs but once in life." 2 

The period of incubation is very short — from four days to a week ; 
and Heberden, Plenk, Rayer, and Gregory, speak of it as latent, 
affording no symptoms ; but Dr. Willan states that occasionally the 
patient complains of languor and somnolency, with a furred tongue, hot 
skin, and quick pulse, with sore throat, and rheumatic pains. Dr. Bate- 
man says that "some degree of fever generally precedes the eruption of 
varicella for a couple of days, which occasionally continues to the third 
day of the eruption. This is sometimes very slight, so that it is only 
recollected as having been previously indicated by fretfulness after the 
eruption appeared. 3 

I have seen the eruption appear without preliminary fever, but I have 
also seen it preceded by irritability, discomfort, dislike of exertion, and 
fever. 

Whether ushered in by fever or not, at the end of a few days the 
eruption appears, sometimes preceded, for a few hours, by a general 
erythematous rash, or a few red patches here and there, upon which 
there appear simple vesicles filled with clear transparent serum, as if 
the skin had been blistered with boiling water. Many of the vesicles 
appear upon the skin with no surrounding redness, but the clear vesicle 
upon the white skin. 

It usually commences on the breast and back, then on the face and 
scalp, and lastly on the extremities, and it appears in successive crops 
for a few days, the old ones dying away whilst the new ones are forming. 

The eruption is accompanied with a degree of itching and tingling, 
and the child generally rubs off the head of the vesicle, and the exposed 
surface becomes irritated and sore ; occasionally they become inflamed 
and a kind of pustule forms, which has led to some confusion. 

If the vesicles remain unbroken for twenty-four hours they become 
opaline and then opaque, and by degrees they dry and form small granu- 
lar scabs. 

There are few or no constitutional symptoms accompanying the 
eruption ; the little disturbance that preceded it generally subsides on 
its appearance ; the tongue is pretty clean, the pulse quiet, the skin 
cool, and the appetite good. After a few days, the scabs fall and all 
traces of the disease disappear. The entire course may be completed 
within a fortnight. 

1 Trans, of College of Physicians, London, vol. i. 

2 On Eruptive Fevers, p. 225. , 3 On Cutaneous Diseases, p. 213. 



VARICELLA. 647 

893. The modifications of the disorder have reference principally to 
the form of the vesicles. Willan described three varieties : the lenticu- 
lar, conoidal, and globate ; which are thus characterized by Dr. Bate- 
man : " the lenticular appears on the first day of the eruption, in the 
form of small red protuberances, not exactly circular, but tending to an 
oblong figure, having a nearly flat and shining surface, in the centre of 
which a minute transparent vesicle is speedily formed. This on the 
second day is filled with a whitish lymph, and is about the tenth of an 
inch in diameter. On the third day the vesicles have undergone no 
change, except that the lymph is straw-colored. On the fourth day 
those which have not been broken begin to subside, and are puckered at 
their edges. Few of them remain entire on the fifth day, but the orifices 
of several broken vesicles are closed, or adhere to the skin so as to con- 
fine a little opaque lymph within the puckered margin. On the sixth 
day small brown scabs appear universally, in place of the vesicles. The 
scabs on the seventh and eighth days become yellowish, and gradually 
dry from the circumference towards the centre. On the ninth and 
tenth days they fall off, leaving, for a time, red marks on the skin 
without depression. Sometimes, however, the duration of the disease 
is longer than the period just stated, as fresh vesicles arise during 
two or three successive days, and go through the same stages as the 
first. 

" In the conoidal varicella the vesicles rise suddenly, and have a 
somewhat hard and inflamed border : they are, on the first day of tneir 
appearance, acuminated, and contain a bright, transparent lymph. On 
the second day, they appear somewhat more turgid, and are surrounded 
by more extensive inflammation ; the lymph contained in many of them 
is of a light straw color. On the third day, the vesicles are shrivelled ; 
those which have been broken exhibit at the top slight gummy scabs, 
formed by a concretion of the exuding lymph. Some of the shrivelled 
vesicles which remain entire, but have much inflammation round them, 
evidently contain on this day purulent fluid ; every vesicle of this kind 
leaves after scabbing a durable cicatrix or pit. On the fourth day, 
these dark brown scabs appear intermixed with others which are rounded, 
yellowish, and semi-transparent. These scabs gradually dry and sepa- 
rate, and fall off in four or five days. A fresh eruption of vesicles 
usually takes place on the second and third day, and as each set has a 
similar course, the whole duration of the eruptive stage in this species of 
varicella is six days ; the last-formed scabs, however, are not separated 
till the eleventh or twelfth day. 

" In the swine-pox or hives (for in the south the former appellation is 
applied to both the second and third species) the vesicles are large and 
globated, but their base is not exactly circular. There is an inflamma- 
tion round them, and they contain a transparent lymph, which on the 
second day of the eruption resembles milk-whey. On the third day the 
vesicles subside, and become puckered and shrivelled, as in the two 
former species. They likewise appear yellowish, a small quantity of 
pus being mixed with the lymph. Some of these remain in the same 
state till the following morning, but before the conclusion of the fourth 



648 VARICELLA. 

day the cuticle separates, and then blackish scabs cover the bases of the 
vesicles. The scabs dry and fall oif in four or five days." 1 

A more severe form is occasionally seen in -which, owing probably to 
the bad constitution of the child, more or less of the vesicles become 
round, clear cut ulcers. Dr. Chas. Johnson mentioned to me a case in 
which each vesicle in the course of 24 hours became an ulcer like 
" burnt holes." 

894. There seems to be no doubt that the disease is both contagious 
and epidemic ; we constantly see it communicated successively to every 
member of a family or school. 

Dr. Bateman mentions that varicella may be propagated by inocula- 
tion with the lymph of the vesicles, and that it may be introduced 
whilst the constitution is under the influence of vaccination, without 
modification of either disease : " that smallpox, inoculated during the 
eruptive fever of varicella, proceeds regularly in its course without oc- 
casioning any deviation in the latter ; but that when variolous and 
varicellous virus is inserted at the same time, the smallpox proceeds 
through its course, while that of the chicken-pox is in a great degree 
interrupted." 2 

Mr. Bryce, of Edinburgh, made many attempts to propagate the dis- 
ease by inoculation, but failed in all. 3 

895. I have already mentioned that, up to the time of Heberden, the 
disease was confounded with smallpox. Since that time many persons 
have regarded it as a modification of smallpox, and recently Dr. Thomp- 
son has maintained this opinion, mainly because, as he states, varicella 
prevails where variola prevails, and never without, and that, therefore, 
the generating miasma must be the same in both ; and that chicken-pox 
is never witnessed in children who have had smallpox. As to the first, 
Dr. Mohl states that from 1809 to 1823, chicken-pox was observed 
annually at Copenhagen without variola. M. Eichhorn mentions vari- 
cellous epidemics without variola, and Mr. Burnes relates a similar oc- 
currence at Carlisle in 1826. Dr. Gregory has also shown that children 
may take chicken-pox after cow-pox, or the reverse, or may have both 
at the same time. Further, the inoculation of chicken-pox never pro- 
duced either variola, varioloid, or vaccinia. 

M. Bayer agrees with Dr. Thompson, and suggests that the chicken- 
pox, which occurs some time after an epidemic of smallpox, may be " a 
last effort of the variolic medical constitution." 4 

M. Alibert does not believe that the miasm of varicella can give rise 
to variola, and he mentions that chicken-pox occurs not merely in those 
who have been vaccinated, but in those who have had smallpox. 5 

MM. Guersent and Blache regard varicella as a disease sui generis, 
and have refuted the positions of Dr. Thompson. 6 

896. Diagnosis. — The very slight fever, or its entire absence, the 

1 Bateman on Cutaneous Diseases, p. 210. 

2 Willan on Vaccination, p. 97. 

3 Thompson on Varioloid Diseases, p. 74. 

4 Diet, de Med., vol. xv. 

6 Monographic des Dermatoses, vol. ii. p. 342. 
6 Diot. de Med., vol. xxx. p. 548. 



SMALLPOX. 649 

vesicular eruption, the clear, watery contents of the vesicles, and the 
insignificant character of the attack, distinguish it from all other erup- 
tive fevers. 

There is some resemblance between it and that variety of smallpox 
which has been termed varioloid, but in the latter there is more fever ; 
the eruption is partly vesicular and partly pustular, and the contents of 
the vesicles are never the clear, transparent lymph we find in varicella. 

897. Treatment. — Little or none is necessary. The child should be 
kept within doors for a few days, abstain from animal food and heating 
drinks, and take a gentle purgative once or twice. 



CHAPTER IV. 

SMALLPOX. — VARIOLA. — PETITE VEROLE. 

898. This is the most distressing and most fatal of all the eruptive 
fevers. It may be defined as a pustular disease, preceded by fever 
which subsides, but is again excited at a more advanced stage ; and 
which terminates in a scab. It is contagious and epidemic and attacks 
a person but once in his lifetime. 

M. Hahn, Dr. Willan, and Dr. Baron believe that the disease was 
known to the Greeks and Romans. Dr. Mead, Dr. Friend, Dr. Gregory, 
and others, maintain the contrary. It was first described by Rhazes, 
and after him by Avicenna, and by innumerable writers since, among 
whom Sydenham decidedly holds the first rank, not merely as an accu- 
rate observer, but as having applied his sound judgment to the improve- 
ment of the treatment. 

Of the period when it was first introduced into Europe, or even into 
England, we know little. Dr. Hillary 1 says that Gilbertus Anglicus 
(1280) and John of Gaddesden (1310 or 1320) allude to the disease as 
one well known. Dr. Monro mentions that some authors have main- 
tained that it was introduced into Europe in the eighth century, on the 
invasion of the Saracens, and into England in the ninth ; but Dimsdale, 
'Mead, and others, place it two centuries later. 2 

In the year 1721 inoculation was introduced into England by Lady 
Mary Wortley Montague, from Constantinople, and was, at that time, 
a great improvement in the history of the disease, in consequence of the 
diminished mortality which it insured. This has been superseded by 
the glorious discovery of Dr. Jenner, and is now abolished by Act of 
Parliament. 

Mr. Wilde has shown satisfactorily the antiquity of this disease in 
Ireland ; he observes that " the time at which this disease first made 
its appearance in Ireland has not been as yet fully determined ; it must 

1 A Practical Essny on the Smallpox, 1740, p. 19. 

2 Monro on the Smallpox, p. 48. 



650 SMALLPOX. 

have been in existence long prior to the date of the English and Latin 
authors of the fifteenth and sixteenth centuries ; for the Irish manu- 
scripts refer to it at the beginning of the fifteenth century ; it is de- 
scribed in the Book of O'Shiel under the name of bolgach, which means, 
literally, blisters or pustules containing matter ; but water-blisters (vesi- 
cles or bullae) are generally termed clog. One of the Irish translators 
iii the fifteenth century states that smallpox and measles (which in the 
manuscripts are generally mentioned together) form in pustules all over 
the body, and are generated from a vitiated state of the red blood and 
humors ; but that the smallpox is produced from a vitiated state of the 
red blood alone, and measles from a depraved condition of the humors. 
The work of Bernard on the smallpox and measles is mentioned in the 
Book of O'Shiel." " The total number of deaths from this cause during 
the ten years amount to 58,006, in the proportion of 100 males to 96*45 
females." " The proportion of this to the general mortality appears 
from the returns to be 1 in 20-46, and, compared with all of the epidemic 
class, 1 in 6*57 ; being, next to fever, the most fatal epidemic affection 
in the country." 1 

Smallpox has been divided into discrete and confluent, mild and ma- 
lignant, with several subdivisions. I shall first describe the disease as 
we ordinarily see it, and then its modifications. 

899. Symptoms. — For the facility of description I shall, as in the 
case of measles and scarlatina, divide the disease into periods or stages. 

I. Period of Incubation. — After exposure to contagion a certain 
period elapses before the child shows any symptoms of being affected, 
beyond, perhaps, some uneasiness, an unwillingness to play as usual, 
and an "unquiet silence," as M. Alibert expresses it. It is not easy 
to fix the length of this period: Boerhaave and Stoll say six or seven 
days; Dr. Gregory from ten to sixteen days. 

II. Period of I?ivasion. — At the termination of the period of incu- 
bation the early symptoms of fever show themselves ; the child is chilly, 
shivering, creeping to the fire ; complains of headache ; is uneasy, cross, 
and hard to please. This state is succeeded by heat and dryness of 
skin, and a quick and full pulse; the appetite is lost; there is nausea, 
with occasional vomiting, generally constipation, rarely an attack of 
diarrhoea. 

The tongue becomes loaded, but red at the point and edges, and ( 
there is great thirst ; the child is completely prostrated, and complains 
of aching in the limbs, the back, the epigastrium, and in various other 
parts. The pain in the loins is so unusually severe that Dr. Gregory 
and others have regarded it as peculiar to smallpox, and aiding in its 
diagnosis in this stage. 

In some cases there is lachrymation, with injection of the conjunc- 
tiva, redness and swelling of the amygdalae, sore throat, and pain and 
difficulty in swallowing. 

In others there is prsecordial oppression, dyspnoea, dry cough, with 
a sense of heat and soreness in the larger bronchial tubes, flying pains 
in the chest, and palpitation. 

1 Report upon the Tables of Death, pp. 11, 12. 



SMALLPOX. 651 

Or this period may be marked by the predominance of nervous symp- 
toms, agitation, restlessness, sleeplessness, or a sudden waking from 
sleep with a start and crying, but nothing more formidable. In more 
severe cases the child may become delirious, or pass into a state of stu- 
por and coma, or be attacked by convulsions resembling epilepsy. 
Sydenham regarded these epileptic attacks as characteristic, where 
there was no irritation from teething, and states that he has foretold 
in such cases the appearance of the eruption of smallpox. 1 

Rayer mentions that these cerebral attacks may prove fatal even 
before the eruption appears, or soon after. 3 

The duration of this period is generally about three days ; occasion- 
ally the eruption appears on the second day, or not till the sixth or 
seventh. 

Generally the eruption is earlier in confluent and severe cases than 
in those where it is discrete and slight. 

In twenty-six cases of normal variola, Rilliet and Barthez state that 
the duration of this stage was one day in one case; two days in eleven 
cases; three days in nine cases; four days in four cases; and six days 
in one case. Of thirty-five abnormal cases, it was a few hours in one 
case ; one day in four cases ; thirty-one hours in one case ; two days in 
twelve cases; three days in five cases; four days in six cases. 3 

III. Period of Eruption. — This stage dates from the first papular 
appearance to the time when the pustules are filled with pus. At the 
first we observe small round isolated spots, which soon become full, 
solid, and prominent papulae, of a more or less vivid red color, which 
disappear under pressure to reappear immediately. We observe them 
first on the face, then on the neck, and by degrees upon the limbs, 
body, hands, and feet. 

These papulae gradually increase in size and change their character. 
The epidermis on each is slightly elevated by a drop of serum of a yel- 
lowish-white color, not so transparent as that of varicella. The time of 
this change is not the same for all the papulas, inasmuch as they appear 
in successive crops on different parts of the body, and the earlier ones 
become vesicular the first, then the others in the order of their succes- 
sion, occupying from twenty-four hours to two or three days in the pro- 
cess. Rilliet and Barthez think that the length of this period is in- 
versely as the length of the prodromi. 

At first the vesicles are small, especially upon the papulae which 
were acuminated, but by degrees they become flattened at the top, 
and spread out laterally until they cover the papula and are much 
larger than it. They lose their semi-transparent character, and become 
opaline. The vesicles are surrounded by an inflamed base, sometimes 
flat, in other cases somewhat elevated above the level of the skin: if 
the vesicles be not too distant, their areolae are in contact, so that the 
skin is of a bright red color between the vesicles. 

The vesicles themselves vary in number, and, when numerous, may 
run into each other, constituting what is called "confluent smallpox," 

1 AVorks, vol. ii. p. 153. 2 Traite des Mai. de la Peau, vol. i. p. 51G. 

3 Mai. des Enfans, vol. ii. pp. 441, 442. 



652 SMALLPOX. 

and exhibiting just such severity of symptoms as might be expected 
from the extent of inflamed and suppurating surface. This confluence 
may occur in patches of different sizes over the surface, but especially 
upon the face, which is now more severely affected than any other part. 

On the body and limbs the vesicles are generally distinct, and when 
they are universally so, it is called "discrete smallpox." 

The papulas assume the character of vesicles about the second day; 
sometimes, though rarely, a day later, and in about two or three days 
more they again change and become pustular. The vesicle which had 
spread out and become flatter now becomes depressed in its centre, 
leaving the borders round and elevated ; the serum, which had become 
opaque, now becomes purulent, and the eruption has the pustular ap- 
pearance, at first on the face, then the neck, body, limbs, &c, just in 
the order in which it appeared. 

This observance of a regular order of succession is remarkable; in 
consequence of it, we may see in the same case papula? and vesicles, or 
vesicles and pustules, but never papulae and pustules, because the time 
required to convert the vesicles into pustules has been sufficient for the 
transformation of all the papulaa into vesicles. 

The duration of this period is from four to six days. 

The fever and general disturbance we noticed during the period of 
invasion continue for a short time after the appearance of the eruption, 
and then either disappear or are considerably reduced in severity ; but 
as the disease assumes its true character we find considerable irritation 
of the mucous membrane of the mouth, pharanx, and larynx. Some- 
times the tongue is much swollen, and there is a profuse discharge of 
saliva. The face also — especially the eyelids — and the neck, are 
swollen. 

IV. Period of Suppuration. — It is somewhere about the fifth or sixth, 
or, according to Sydenham, the eighth day, that suppuration com- 
mences ; the liquid in the vesicles, from semi-transparent, becomes 
opaque, then of a dull white, and lastly of a yellow color; at the same 
time the pustules increase in size, the depressed centre is again raised, 
and they become more spherical. 

On the extremities we occasionally find pustules which preserve their 
opaline character during the entire of this period, and others which 
assume a livid appearance, as if from the effusion of blood. 

On the surface of the pustules themselves, at the beginning of this 
stage, we may observe small semi-transparent gray or yellow points, 1 
the former owing to an arrangement of the epidermis, the latter to, new 
matter deposited under the epidermis. Rilliet and Barthez call these 
" pointilles de couleury They are generally seen upon the pustules of 
the face, or on the body and thighs, and they disappear about the 
seventh or ninth day of the eruption, when the pustules are completed, 
or perhaps just as desiccation commences. On the pustules of the 
hands, feet, and arms, instead of these points, we may observe concen- 
tric circular marks, gray and semi-transparent, or clear yellow, alter- 
nately. When two pustules touch, the outer yellow circles of each are 

1 Rilliet and Barthez,. Mai. des Enfans, vol. ii. p. 449. 



SMALLPOX. 653 

broken and confused. The gray circles are broader at the commence- 
ment, but the yellow ones increase until they occupy the entire pustule. 

The process of pustulation follows exactly the same order as the 
development of the papulae; those on the face, which appeared first, being 
first perfected, then those on the neck, body, limbs, hands, and feet. 

The more advanced the eruption, the more confluent it appears; and 
the more abundant the crop of pustules, the more confluent they become, 
because this gradual increase which we noticed brings them into con- 
tact with each other; and many parts which were very distinct at the 
beginning, end by becoming quite confluent. 

The period of suppuration lasts from four to six days, and it is marked 
by a return or an increase of the fever; but in this stage it is called the 
suppurative or secondary fever. Its amount or intensity is generally 
in proportion to the extent and confluence of the eruption ; slight in 
discrete smallpox, it acquires great severity in the confluent form ; the 
pulse ranges from 100 to 140, full, strong, and regular ; the skin is 
very hot and dry; there rarely is any perspiration. 

The face is enormously swollen, the eyelids quite closed, and the 
aspect utterly changed and frightful. 

In addition, the mucous membrane of the fauces, pharynx, air-tubes, 
and digestive passages, is in a state of great congestion and irritation, 
if not of inflammation. 

"In a large portion of confluent and in some semiconfluent cases, the 
mucous membrane of all these parts to which the atmospheric air gets 
access (the nose, mouth, and trachea) is occupied with the eruption, 
sometimes distinct, more generally confluent. The only symptoms oc- 
casioned by this mucous complication are as follows: numerous white 
points appear on the tongue, palate, and velum pendulum. Hoarseness 
and alteration of voice indicate that the same condition extends to the 
mucous membrane of the larynx and trachea. There is great pain and 
swelling, and, in bad cases, cough and dyspnoea. The cough is at first 
dry and teasing; as the disease progresses, there is expectoration; about 
the eighth day, a copious viscid secretion takes place from all the 
affected structures." 1 

In many cases there is delirium, agitation, coma, &c, so that at a 
later period of the disease we seem to have its first acute febrile and in- 
flammatory character reproduced, and this continues until the desicca- 
tion has fairly set in. 

This secondary fever is supposed to result from absorption of the 
purulent matter, and its mixture with the blood. If the eruption be 
limited, the quantity of purulent matter absorbed is small, and the result 
is fever, without complication; but in very confluent cases, the amount 
of purulent matter absorbed is sufficient to taint the whole system, and 
to produce all those phenomena which result from such a poison analo- 
gous to those which arise from phlebitis, such as typhoid or ataxic 
fever, metastatic abscesses in the lungs, liver, and cellular tissue; 
arthritis with effusion, &c. 

Sydenham seems to allude to this result when speaking of the epi- 

1 Gregory on Eruptive Fevers, p. 47. 



654 SMALLPOX. 

deuiic of 1674 : " Of this I am certain, that the present smallpox 
exactly resembled that of the preceding constitution, only it seemed to 
be of a grosser nature, and attended with a much greater degree of pu- 
trefaction. And from these two causes it followed that when the erup- 
tions were very confluent, it destroyed abundance more than any other 
sort I had yet seen, and in my opinion proved as fatal as the plague 
itself," &C 1 

" Often, indeed," says Dr. West, "it assumes a typhoid character; 
the pulse becomes extremely frequent and feeble ; the tongue dry and 
brown ; and the patient dies delirious. In other instances, the matura- 
tion of the pustules goes on for a day or two, with very slight reaction ; 
and were it not that this extreme mildness of the secondary fever, in 
cases where the eruption has been abundant, is itself a suspicious cir- 
cumstance, we should be disposed to express, without hesitation, a most 
favorable opinion as to the patient's condition. Suddenly, however, 
the pulse begins to falter, the pustules, which before seemed full, col- 
lapse ; the extremities grow cold ; and in a few hours the patient dies. 
This fatal change is sometimes ushered in by a fit of convulsions ; at 
other times it is preceded by a condition of extremest restlessness, which 
contrasts remarkably with the extreme quietude of the child's manner 
for the two or three previous days." 2 

V. Period of Desiccation. — Like the other phases of the disease, 
this further process commences in the face first, so that this part may 
be covered with crusts at a time when the pustules are but just arrived 
at maturity upon the limbs. The tumefaction diminishes, the pustules 
dry up, and the crusts which result form a mask over the entire face. 
The features are hidden by a thick, brown incrustation, which falls off 
about the fifth or sixth day after its formation, to be succeeded by fur- 
furaceous scabs, which fall, and are renewed several times before the 
skin is clear. The more confluent the disease, the more humid are the 
crusts. But when the pustules ulcerate, which is very common in con- 
fluent smallpox, some blood may escape, which will give to the crusts a 
black color ; and when they fall off, we find the skin irregularly de- 
stroyed, so as to form pits, seams, or cicatrices, which give to the 
countenance a very frightful appearance. These pits or seams are 
much more frequent on the face than in any other part of the body, 
because it is there that the eruption is more abundant and confluent, 
and that the inflammation, being more intense, is more liable to run on 
into ulceration of the cutis. 

The odor from the patient during this period is most offensive and 
sickening ; the tenderness of the surface is so great, that it is impossi- 
ble to observe great cleanliness ; and the accumulation of purulent 
matter, the extent of suppurating surface, the fetid breath, occasions a 
disgusting and impure atmosphere around the patient. 

A very distressing itching accompanies the formation of crusts, the 
more annoying as rubbing or scratching the parts is attended by pain, 
and leads to still greater disfigurement. 

1 Works, vol. ii. p. 322. z Diseases of Infancy and Childhood, p. 468. 



SMALLPOX. 655 

M. Rayer, 1 Rilliet and Barthez, and others, mention that in some 
cases there is neither desquamation nor formation of crusts ; the pus- 
tules become flat in the course of forty-eight hours, owing, probably, 
to the absorption of the pus, and that, coincident with this change, 
there is a sudden prostration and other phenomena analogous to those 
observed in animals into whose veins pus has been injected. 

Rilliet and Barthez have described several modes in which this desic- 
cation takes place. 2 I. In the first, the epidermis of the pustule cracks 
in the centre or circumference, and the pus and false membrane, being 
exposed to the air, concrete into a yellow crust, at first moist, then dry, 
rough and unequal at first, occupying only a portion of the pustule, 
but afterwards occupying the entire : it is connected with the neighbor- 
ing ones at its circumference. 

II. In other cases, a small, dry, yellow, semi-transparent crust is 
formed occupying the entire pustule, and if we detach it, the surface 
underneath will be found red, moist, elevated, and perhaps bleeding ; 
when the crusts fall, they leave a red, uniform level surface, which 
gradually loses the red color, and exhibits no cicatrix. 

III. A small scale may form in the centre of the pustule, surrounded 
by purulent matter, the epidermis having desquamated and being de- 
tached. This mode leaves no mark. 

IV. Lastly, the pustules do not break, but become gradually flattened 
from the absorption of the pus, and the epidermis, smooth and softened, 
is separated from the cutis by a layer of false membrane, which forms a 
thin crust of a yellow color, and which, with the epidermis, dries and 
falls off in large scabs, leaving a smooth and slightly red surface under- 
neath. 

900. Let us now inquire as to the eruption upon the mucous mem- 
branes. Small elevations, surrounded by a circle of inflammation, may 
be observed in the mucous membrane of the mouth and fauces, and at 
the end of two or three days these change color, and become white or 
gray, and on their surface there is a small patch of false membrane, 
which is detached after a few days, leaving a slight erosion, or super- 
ficial ulceration, which is not followed by a cicatrix. 

In the pharynx and oesophagus, pustules are occasionally observed, 
somewhat modified by the structure of the part, and pustules have also 
been observed at the rectum. 

Death may take place at any stage — before the appearance of the 
eruption, during its course, or after desiccation. In 168 fatal cases 
mentioned by Dr. Gregory, death occurred between the third and 
seventh days in 32 ; between the eighth and twelfth, in 88 ; between 
the twelfth and twentieth, in 39 ; and between the twenty-second and 
thirty-eighth, in 16 cases. 

901. Modifications. — The preceding description embraces only ordi- 
nary cases of smallpox, but we find in practice that in many cases the 
appearance and course of the disease deviates widely from the ordinary 
standard, and in others, whether normal or anomalous, it is very seri- 

1 Mai. de la Peau, vol. i. p. 520. 2 Mai. des Enfans. vol. ii. p. 465. 



656 SMALLPOX. 

ously complicated with some organic affection. Let us inquire a little 
into each of these phases. 

a. It sometimes, though rarely, occurs, that there are either no pre- 
cursory symptoms, or that they are unusually short in duration. On 
the other hand we sometimes see the fever lasting several days, with no 
other symptom, or with only diarrhoea. Much depends, no douht, upon 
the previous state of health, and whether the variola is primary or 
secondary. 

b. The eruption may appear irregularly, showing itself first upon the 
body or arms, and thence spreading to the face; or it may appear full 
on the face and very sparingly upon the body. 

In some cases the eruption scarcely assumes the true pustular charac- 
ter, or, whilst some of the spots go through their proper course, others 
remain vesicular, with clouded serum instead of pus. 

c. In some very severe and fatal cases the pustules are red, livid, or 
filled with blood {hemorrhagic variola, or black smallpox of Sydenham). 
In other cases we may find petechias or ecchymoses in different places, 
with hemorrhage from the kidneys, bowels, &c, speedily carrying off 
the patient. My friend, Mr. Smyly, has given me the notes of two such 
cases, and it is remarkable that in such cases the eruption is seldom, if 
ever, fully developed ; it may remain either papular or vesicular. 

As this form of the disease is comparatively rare now, it may be 
worth while extracting the following graphic description from Dr. Hil- 
lary's work: — 

"The bleeding smallpox is the very worst sort, and seems to proceed 
from a conjunction of several of these causes in their most violent 
degree. The infection is probably the most pernicious, the habit of the 
person unfavorable, and strongly disposed to receive the infection." 
" The invasion is mostly attended with convulsive, racking, lancinating 
pains in the lower part of the back and loins, so intolerable that at every 
spasmodic shoot the patient cannot refrain from starting and crying out 
as if he were stabbed with a sword ; he has also a violent shooting pain 
in his head; his eyes are extremely inflamed; he breathes very quick, 
short, and laboriously, and his pulse is quick, weak and frequent: though 
sometimes the purple spots and hemorrhages will come on without any 
other symptoms but the two last, though not often. The sick have 
first a flushing in their faces, breasts, and backs, and shortly after a 
redness like that in the scarlet fever appears all over the body ; the 
pustules do not rise, but stand in the skin like a flat, continued, red 
swelling; after this redness an infinite number of small red or purple 
petechias will appear all over the body and limbs, which afterwards turn 
to a dusky brown, livid, or black color, and sometimes spread very 
broad : the pustules, likewise, are spotted or turn black in the middle, 
which dimple in and do not rise. Sometimes a colliquative profuse 
salivation comes on thus soon, which is afterwards often mixed with 
blood." 1 

d. Again, the vesicles and pustules may be either unusually small or 

1 On the Smallpox, p. 123. 



SMALLPOX. 657 

unusually large. In the latter case they are flattened and not dis- 
tended, and the false membrane has not its usual character. 

Occasionally large bullge are seen on the limbs, wrists, ankles, &c, 
but never on the face, filled with serum, and, when dried, forming large 
scales. This was noticed by Sydenham in the epidemic of 1670. 

e. The fever, which ordinarily subsides very much, if not completely, 
when the eruption appears, in other cases continues unabated in in- 
tensity. 

/. Suppuration may not take place satisfactorily; it may be incom- 
plete or excessive, or mixed with hemorrhagic blotches. The fever may 
take a typhoid type, and very formidable complications occur. 

g. Varioloid. — A modified kind of smallpox, which is termed vario- 
loid, occurs occasionally either after vaccination, inoculation, or casual 
smallpox, and it is more frequent after the age of fourteen than before, 
perhaps from the vaccine influence having worn out. The precursory 
symptoms are not generally severe, though in some cases there is a 
smart febrile attack. The eruption is not ordinarily very extensive, 
and chiefly occupies the face and trunk. It does not assume the flat- 
tened pustular form, but is more spherical, and is filled with yellow 
serum or pus. After a few days the vesicles or pustules dry up and 
form small round scabs, which fall off, and leave no indentation after 
them. The fever subsides as soon as the eruption appears, and there is 
no secondary fever. 

The extent of pustulation varies much; some have only ten or twenty 
spots; others, as I have seen, are pretty well covered with them. 1 

It rarely happens that any complication aggravates the attack. 

It is undoubtedly contagious, and it has been remarked that it may 
reproduce true smallpox in another person. 

It is doubtful whether an attack of varioloid affords protection from 
smallpox subsequently. 

h. Ordinarily smallpox attacks an individual but once in his life ; 
there are, however, well-authenticated cases on record where it occurred 
a second or even a third time, though in general these assume the form 
of varioloid. 2 

i. " During the prevalence of epidemic smallpox numerous cases of a 
febrile affection frequently occur, marked by tenderness of the epigas- 
trium, pain in the back and limbs, some degree of soreness of the throat, 
salivation, profuse perspiration from which no relief results, and not 
unfrequently petechias. This has been denominated variolous fever with- 
out eruption. This fever generally begins and ends with the variolous 
epidemic. We have repeatedly met with such cases, as well in the un- 
protected as in those who have been vaccinated, or who had previously 
had the smallpox. That the disease results from the same infection as 
the smallpox we have no doubt; how far it affords subsequent immunity 
from the latter we have had no means of judging." 3 

902. Complications. — I. The nervous system is frequently more or 
less involved. I have already stated that headache is an accompaniment 

1 Monro on Smallpox, p. 233. 

2 Gregory on Eruptive Fevers, p. 73 ; Monro on Smallpox, p. 77. 

3 Condie, Diseases of Children, p. 509. 

42 



658 SMALLPOX. 

of the fever, and that we may also have delirium, agitation, stupor, 
coma, or convulsions, in the period of invasion. We have seen how 
characteristic Sydenham thought the epileptiform attacks, and I may add 
that head symptoms are by no means uncommon in the suppurative 
stage of bad cases. : p 

Dr. Condie observes that "the same affection' of the brain that fol- 
lows the destruction of large portions of the skin by burns or scalds often 
occurs. The symptoms are severe: repeated rigors, followed by general 
tremors ; a quick, thready, and tremulous pulse ; a dry brown tongue ; 
collapse of the features ; cold extremities ; subsultus tendinum ; and 
death." 1 

Of 112 patients who died of the disease in 1825, M. Guersent did not 
find a single example of meningitis or encephalitis, but occasionally a 
kind of passive injection of the membranes. 

I need not add that any cerebral attack is a most formidable compli- 
cation, and may in itself prove rapidly fatal. 

II. Coryza — Epistaxis. — A sero-sanguinolent discharge from the nos- 
trils is by no means unfrequent, owing to the inflammation and pustula- 
tion of the mucous membrane of the nose. 

III. Laryngitis. — Croup occurs occasionally in the course of small- 
pox, but not very frequently. 

IV. Bronchitis alone is rare, and not very important, but it is not 
unfrequently complicated with pneumonia. It rarely occurs before the 
tenth day. 

v. Pneumonia. — Inflammation of the lungs is not very uncommon, 
and it has a serious influence upon the result of the variola. Accord- 
ing to Rilliet and Barthez, " the pneumonia of variola commences either 
during the first days of the eruption, or during convalescence. In the 
first cases, the variola was secondary and anomalous, two patients hav- 
ing varioloid, one normal, the other abnormal, so that it may be ques- 
tioned whether the irregularity depended upon the primary disease, or 
■upon the pulmonary complications. We think that both causes may 
have contributed to produce this effect. On the contrary, in the second 
series, the variola was primitive and normal; the complication had no 
influence upon the eruption. With one only of our patients the pneu- 
monia occurred at an intermediate period, i. e., on the eighth day of 
the eruption ; the variola was abnormal; the effect of the pneumonia 
was to discolor it almost instantly, and to add to the previous irregu- 
larity a remarkable paleness. 

" Pneumonia, rare, and without bronchitis, may be overlooked in our 
investigation. When more extensive, it is only by auscultation and per- 
cussion that it is known, and these methods are sometimes difficult to 
use ; the disgusting odor, the necessity of interposing several layers of 
linen between the sufferer and the ear, occasion us to overlook the 
pneumonia until the autopsy. The cough hardly draws attention to the 
pulmonary organs, inasmuch as it may be caused by the pharyngo- 
laryngitis: but when at the period of desiccation the symptoms increase 
instead of diminishing, we may suspect some pulmonary disease, and 

1 Diseases of Children, p. 508. 



SMALLPOX. 659 

call to our aid auscultation for its detection. The prognosis of variolous 
pneumonia is very serious, but the mortality is greater in the irregular 
forms of variola. The pneumonia is less serious when it occurs during 
convalescence, and particularly when it is lobar." 1 

Fabre states that lobar is more common than lobular pneumonia. 

vi. Salivation. Muguet. — In some cases we find a continual dis- 
charging of a viscid, limpid, and frothy fluid from the mouth. It gene- 
rally occurs from the fourth to the eleventh day, but Rilliet and Barthez 
have seen it come on on the eighteenth ; and chiefly about the age of 
six years or after. It attacks those who recover as well as those who 
die, and most frequently in the anomalous and confluent variola. 

It may, perhaps, be owing to the inflammation or pustulation extend- 
ing up the salivary ducts, or perhaps to sympathetic irritation. 

Pseudo-membranous inflammation of the gums, mouth, or pharynx, 
may occasionally be observed, and, in a very few cases, gangrene of the 
mouth. 

VII. G-astro-enteritis. Enter o- Colitis. — We have seen that smallpox 
may be accompanied with great irritation of the stomach, vomiting, &c. 
This may continue some days, and then cease, and it may return at a 
later period. The digestive functions are, of course, suspended during 
the disease. Dr. Gregory states that " smallpox is singularly exempt 
from all abdominal complications," but that mucous enteritis sometimes 
occurs. 

But the lower portion of the intestines is much more commonly affected 
in variola, as Guersent and Blache have observed, and this is one of the 
most common complications of the eruptive disease. In the normal 
form it commences from the eighth to the twenty-fourth day, and rarely 
before, but in the abnormal it may show itself on the first or second 
day. Diarrhoea is the symptom which is present in almost all these 
cases of entero-colitis, sometimes after constipation, with swelling, ten- 
sion, and tympanitis of the abdomen, and sometimes without. It is 
always a very serious, often a fatal, complication. 

viii. Hemorrhages. — In severe typhoid cases of smallpox we 
occasionally find a discharge of blood from different organs, epistaxis, 
bleeding from the gums, petechia on the skin, hemoptysis, hematuria, 
and hemorrhage from the intestines. None of these are very common, 
but all are of importance, either in themselves when extensive, or as 
indicating a very deteriorated condition of constitution. All these 
attacks have been noticed by Sydenham, and others since his time. 

IX. Ophthalmia. — No portion of the mucous membranes shows more 
distinctly or more frequently its participation in the pustular eruption; 
not merely is the conjunctiva inflamed but the deeper tissues are in- 
flamed, softened, and ulcerated ; especially the cornea. Riliet and 
Barthez have noticed different degrees of keratitis. In the first there 
were slight spots upon the cornea, surrounded by a red circle, and with 
great congestion of the vessels of the conjunctiva. 

In the second, ulceration had taken place; in some to a limited 
extent, and followed by recovery ; in other cases the eye was lost. 

1 Mai. des Enfans, vol. ii. p 503. 



660 SMALLPOX. 

Hernia of the iris may result in such cases, or the transparent cornea 
become hopelessly opaque. 

This affection of the eye is generally observed at an advanced period 
of the disease. 

x. Otitis. — Less common than ophthalmia, we now and then do meet 
with cases of inflammation of the external meatus or internal ear, 
terminating by resolution most frequent]}'', or in abscess with severe 
suffering. It generally occurs towards the decline of the disease. 

XI. Abscess. — Subcutaneous abscesses are sufficiently frequent, and 
as the patients in whom they occur generally recover, they have been 
regarded by some writers as critical. 

In some cases they appear independently as the result of the violent 
inflammation which the skin has undergone, and in others they are 
probably connected with rheumatism. Killiet and Barthez observe: 
" Besides these patients six others had abscesses, more or less numerous, 
in different parts of the body, and particularly around the articulations. 
Two out of twelve or fifteen of these abscesses followed upon consider- 
able swelling of the subcutaneous tissue. In fact the children had at 
this period severe pains, which diminished with the general swelling. 
But the local tumefaction continued, and soon after fluctuation became 
perceptible. 

" In other cases the first evidence of suppuration between the thir- 
teenth and thirty-second day, was pain, accompanied by swelling, heat, 
and redness in some part of the body, and, when near an articulation, 
simulating very accurately articular rheumatism. However, in a few 
days suppuration was evidently established, and the abscess being 
opened gave exit to pus, sometimes sanious, sometimes thick and 
healthy, and then cicatrization took place after a longer or shorter time. 

"Two patients alone had a single abscess; the others had two, three, 
or four, in different parts of the body. We observed them on the chin, 
at the anterior iliac spine, in the parotid, but more frequently around 
the shoulder, the elbow, and the joints of the thigh or foot. In all 
cases except one, cicatrization was sufficiently speedy. Of the six 
patients, five recovered and one died." 1 

xii. Rheumatism. — The preceding paragraph will show that articular 
rheumatism occurs occasionally, though not very frequently. Killiet 
and Barthez remark: "Four patients exhibited symptoms which re- 
sembled those of articular rheumatism, i. e., tumefaction and pain 
about several joints, sometimes with redness. These symptoms were 
of short duration, and in two cases there was metastasis from one joint 
to another, although it is true that in one of these cases there was an 
interval of twenty-two days between the inflammation of the two joints." 
"Of ten cases of arthritis, or of abscess, six had normal variola; 
three abnormal variola, and one varioloid. Of the entire, eight were 
cured; one died during suppuration; and another a long time after the 
disappearance of the rheumatism." "It is impossible, with such facts 
before us, not to regard these inflammations and abscesses towards the 
end of variola as a critical symptom of favorable augury." 2 

1 Mai. des Enfans, vol. ii. p. 495. z Ibid. 



SMALLPOX. 661 

xiii. Eruptions. — I have already mentioned the occurrence of 
petechias, resembling those of purpura hemorrhagica, and of bullse, 
both unfavorable symptoms, and occurring only in the worst kind of 
cases. 

Guersent and Blache mention having seen the favi of porrigo form 
upon the pustules of smallpox. Rayer, and Killiet and Barthez, 
observed mercurial erythema follow the use of mercurial plasters. 

But, what is more remarkable, measles and scarlatina may occur, 
either along with smallpox, just previously, or immediately after. 

Sydenham mentions that the irregular black smallpox was introduced 
by an epidemic of measles, in 1670, and also the singular variety which 
appeared in 1674-5. 

Nay more, the vaccine vesicle may maturate coincidently with small- 
pox. In November, 1849, my son vaccinated an infant, and the vesicle 
rose well and maturated, but about the sixth day an eruption appeared 
over the body which turned out to be smallpox, of which the child died. 
It is to be presumed that the child took the infection before the vaccina- 
tion. I have since seen a similar case myself. 

xiv. Other complications have been observed, but less frequently 
than those I have noticed. Anasarca occurs occasionally at the begin- 
ning or during the desiccation, and oedema of the lung. Pleurisy and 
pericarditis have been sometimes observed, but neither of these is of 
frequent occurrence. 

903. Pathology. — A post-mortem examination reveals considerable 
congestion of almost all the organs of the body. The muscles are of 
a deeper red color than usual ; the vessels of the brain and its mem- 
brane are distended ; the lungs, liver, spleen, and kidneys, are more or 
less congested or inflamed. The blood is a good deal changed ; it is 
almost entirely fluid, of a dark color, and unusually serous ; or, if there 
be coagula, they are small, soft, and of a dark color. 

From the eruption being more abundant where the cutaneous follicles 
abound, MM. Petzholdt, Rilliet and Barthez, regard them as the true 
seat of the pustules of smallpox. 

This pustule, at its origin, is but a macula resulting from the vascular 
injection of the mucous tissue of Malpighi. Shortly afterwards, the 
surface becomes raised, and a pustule is gradually formed; in its interior 
there is a circular false membrane which is attached by a threadlike 
process to the cutis on the one hand, and to the epidermis on the other, 
and this it is which causes the depressed centre of the pustules. Be- 
neath this membrane there are small cells, containing a serous fluid, 
and without intercommunication. At a late period, when pus is formed, 
it penetrates between the epidermis and the membranous disk, ruptures 
the adhesions, and gives a globate form to the pustule, which has thence- 
forward only one sub-epidermic cell. 

If we divide a fully formed pustule, we may perceive at its base the 
pseudo-membranous disk, underneath which the cutis is red and often 
inflamed. 

Cotugno enumerates thus the tissues to be seen in a pustule divided 
vertically : 1. A white line formed by the thickened epidermis ; 2. 
Beneath, a purulent layer ; 3. Still lower, a red line, formed by the 



662 SMALLPOX. 

inflamed rete mucosum ; 4. Underneath which is the unaltered chorion ; 
5. In the centre of the pustule a small white body, whose superior fili- 
form extremity is implanted in the centre of the depression (umbilicus), 
whilst the inferior is attached to the inflamed corpus reticulare. 

MM. RilHet and Barthez do not agree with M. Rayer 1 as to the for- 
mation of the umbilical depression, because it exists when there is no 
membranous disk. They prefer M. Petzholdt's 2 explanation, who attri- 
butes it to the traction excited upon the epidermis by the excretory ducts 
of the cutaneous glands. 3 

They have thus stated the different degrees of suppuration in different 
parts of the body : 1. In the face, and sometimes on the limbs, the 
ulceration extends to the chorion more or less deeply, with a true sup- 
puration, and followed by persistent cicatrices. 2. On the limbs most 
frequently, and sometimes on the face, there is inflammation of the sub- 
epidermic layer, with erosion and suppuration, but no cicatrix. 3. If 
the cutis be not eroded with inflammation of the sub-epidermic layer, 
there will be a serous secretion at first, then one of plastic lymph, but 
no cicatrix ; 4. The serous secretion may be deficient, and then the false 
membranes will not be abundant, and the pustules will be flat, &c. 4 

904. The mucous membrane of the mouth, larynx, pharynx, and, in 
short, any portion possessing epithelium, is the seat of pustules, but 
which are modified in some degree by the peculiarities of the structure, 
and when the epithelium has been removed, exhibiting superficial ulcera- 
tions, which may be increased in extent by the junction of several. 

Pustules are also observed in the oesophagus, but not so frequently. 
It is a matter of dispute whether any true pustules have been found in 
the stomach. M. Guersent believes that he has seen them several times 
in the stomach and in the small and large intestines. 

M. Rostan 5 found them in the large intestines and in the rectum, and 
Cotugno 6 observed them upon the mucous membrane of a prolapsus ani. 

Rayer and Rilliet and Barthez deny that they exist in the intestines, 
and attribute the appearance which has been mistaken for them to the 
development of the mucous follicles. 

Dr. Condie mentions that in the epidemic of 1823-4, at Philadelphia, 
in almost every case, the stomach and upper portion of the small intes- 
tines were diseased. 

The larynx, trachea, and principal bronchial tubes exhibit the vario- 
lous pustules upon their mucous membranes, and, in common with the 
gastro-intestinal surface, present appearances of congestion and inflam- 
mation. 

905. Causes. — Among the predisposing causes are age, sex, and sea- 
sons. It occurs at all ages, nay even before birth, 7 as has been observed by 
Mead, Jenner, 8 Laird, Hosack, Aulsebrook, 9 and others, and undoubtedly 
children are more subject to it than adults, and adults than old people. 
.For a reason I have mentioned before, I attribute the predominance of 

1 Mai. de la Peau, vol. i. p. 529. 2 Archives Gen. de Med., 1838, vol. ii. p. 814. 

3 Mai. des Enfans, vol. ii. p. 450. 4 Ibid., p. 453. 

5 Diet, de MeU, vol. xxi. p. 196. 6 De Sede Variolarum, p. 152. 

7 Graetzer Krankheiten des Foetus, p. 27. 

« Med.-Chir. Trans., 1809, p. 269. 9 Lancet, Sept. 2, 1854. 



SMALLPOX. 663 

the smallpox among young children to the fact of their taking it the first 
time they are exposed to the contagion, rather than to any greater sus- 
ceptibility in children than in adults. Rilliet and Barthez have remarked 
that the anomalous variety is more common among young infants, and 
the normal form among older children. The disease is not so frequent 
apparently, among very young infants, as measles and scarlatina. 

It does not appear that the one sex is more liable to the disease than 
the other. 

Smallpox, when it prevails epidemically, commences, according to 
Sydenham, about the vernal equinox, and is prolonged during summer 
and autumn, when the disease is mild and regular, but when it is irre- 
gular it appears sooner. 1 

906. The chief agent in the spread of variola is contagion or infec- 
tion. No one doubts, I believe, that it is contagious, or that it may be 
conveyed to a distance, but how far the sphere of its contagion extends 
is not easy to determine. Dr. Williams has fixed from thirty to fifty 
feet. Dr. Gregory thinks that the contagious miasm is given off at 
every stage of the disease, ""from the first invasion of fever to the 
throwing off of the latest scabs." 

That it may be conveyed in the air and by clothes is also admitted. 
In an interesting monograph, lately published, Dr. T. H. Buckler, of 
Baltimore, conceives that it may have been transmitted by means of the 
paper-money used in that city. From what I have already stated, it 
will be seen that the period of incubation is not precisely determined. 
It may be that it is not always precisely the same under similar circum- 
stances, but, as far as we can judge, it is between four days and a fort- 
night generally. 

There are two other modes by which it may be communicated: 1, 
through the blood of the mother to the foetus in utero, whether the 
mother have the disease or not, as in the cases related by Mauriceau, 
Mead, Watson, Forbes, &c. ; and 2, by means of inoculation, which was 
common in China, India, Africa, Turkey, from whence it was imported 
by Lady M. W. Montague in 1721. It was introduced into America 
in the same year by the Rev. Cotton Mather. 

The disease thus produced is essentially smallpox in almost all cases; 
some few cases of varioloid occasionally result, but it is very much 
milder, not more than 1 in 500 are said to have died. This practice 
has, however, been superseded everywhere by the glorious discovery of 
Dr. Jenner. 

907. The disease also prevails epidemically, and none have been 
more fatal. The desolating effects have been felt by the wild tribes of 
North America, some of whom it has obliterated, as well as the civilized 
inhabitants of Europe, whom it more than decimated in former days. 

It is not, however, easy to give a list even of the principal epidemics. 
Sydenham has left an admirable description of those which prevailed in 
1671, 1672, 1674, 1677, 1678, and 1679 in London, where it was also 
epidemic in 1757, 1781, 1796, 1825, and 1838. 

The disease was introduced into America in 1527, and a severe epi- 

1 Works, by Wallis, vol. ii. p. 152. 



664 SMALLPOX. 

demic occurred in 1633; others at Boston in 1649, 1666, 1678, and 
1690. In 1702 4.4 per cent, of the inhabitants died of it, and in 1721, 
54.6 of the population had it, and 14.3 per cent, died, and it occurred 
in Philadelphia in 1823. 

An epidemic prevailed at Berghen, in Norway, in 1749, and de- 
stroyed 528 persons. One occurred in Norwich in 1819, and destroyed 
530 persons between May and October. 

An epidemic commenced in Sweden in 1824, reached England in 
1825, spread to France in 1826-7, and terminated in Italy in 1828-9. 
In 1838 various towns and country districts of England suffered from 
this plague. 

Dr. Rogers has noticed a very fatal epidemic which prevailed in Cork 
in 1708, and its annual return to that city from 1718 to 1721, and 
from 1728 to 1731. 1 

Dr. Rutty mentions severe epidemics in Dublin in 1728, 1736, 1740, 
1743, 1745, and 1752 ; and it appears that the number of those who 
died of smallpox was little less than those who died of fever. 2 

It prevailed here also in 1837, 1838, 1839, and 1840. Dr. Ring- 
land has given an account of the latter. 3 

908. Diagnosis. — Perhaps there is no disease whose diagnosis is 
more easy when it is fully formed. The intense fever, subsiding on the 
appearance of the eruption, the character of that eruption, rapidly run- 
ning on from papulae to vesicles and pustules, their confluent character, 
and the formation of scabs, serve at once to distinguish it from any 
other eruptive fever. 

It is true that at a very early period we may be in doubt whether the 
child be about to have measles or smallpox, but a day or two will decide ; 
and in some of the anomalous cases we may have to determine that it 
is smallpox, by proving that it can be neither measles nor scarlatina: 
but in general we shall find but little difficulty. 

Prognosis. — Our prognosis must be founded upon the character of 
the disease. If it be discreet and normal, the majority of cases recover; 
when confluent, but normal, there is more danger, but still it is often 
cured ; but when confluent, complicated, and abnormal, it proves very 
fatal. 

M. Bayer remarks : " The gravity of the prognosis is in proportion 
to the number of pustules, the degree of inflammation of the skin of the 
face and mucous membranes, and especially of that of the air-passages, 
the temporary or permanent character of the complications, the presence 
of the petechise, and the amount of passive hemorrhage. It is unfavor- 
able in infants during dentition. 

"If the eruption is successive in confluent variola, the danger is in 
general less imminent; if, on the contrary, the pustules appear at once 
on the face, neck, trunk, and limbs, the disease is one of the most seri- 
ous to which the human frame is liable, and death often terminates it. 
Variola, with cerebral symptoms at its commencement, or in its course, 

1 An Essay on Epidemic Diseases, 1734. 

1 On the Weather, Seasons, and prevailing Diseases of Dublin, 1770. 

3 Dublin Journal, July, 1841, vol. sis. p. 420. 



SMALLPOX. 665 

is very dangerous. Ecchymoses and petechise indicate often a fatal 
change in the blood, and approaching death. 

"Laryngo-tracheitis, croup, and pseudo-membranous bronchitis, ren- 
der the prognosis more and more serious. 

"Obstinate ophthalmia, otitis, caeco-colitis, abscess, or other affections, 
augment the danger during convalescence." 1 

It has always been one of the most fatal diseases of children. Before 
the introduction of inoculation, the mortality was said to be 25 per cent. 

In London, before the discovery of vaccination, the deaths by small- 
pox were to the total deaths as 8 to 100; and in the last century 199,- 
665 persons died of it. 

In Germany, Heim states the mortality to be 20 per cent. At the 
Smallpox Hospital, the average mortality for twenty-five years (from 
1776 to 1800) was 32J per cent. From 1800 to 1825 it was 30 per cent. 

In Philadelphia, from 1786 to 1802, the average relative mortality 
■was 1 in 14, or 7.28 per cent.; from 1807 to 1811, 4 per cent.; from 
1816 to 1841, after the prohibition of inoculation, about 1.66 per cent. 

Throughout England and Wales the deaths now amount to about 
12,000 annually, and Dr. Gregory considers that one in six of those 
attacked may be considered as the average mortality. 

In Dr. Geo. Kennedy's valuable report, I find that in Dublin the mor- 
tality is nearly one in five, taken generally, and of the confluent cases 
nearly the half died. 2 

As might be expected, the younger the child the more fatal the dis- 
ease. Of 3022 deaths of children from this cause in Philadelphia in 
forty years, 1810 occurred in those under ten years of age, and 555 
under one year. Of 9762 who died in England in 1837-8, 7340 were 
under five years of age. 

909. Treatment. — Fortunately in the present day we are rarely called 
upon to treat smallpox, compared with former times ; but even now we 
occasionally meet with it, and our treatment must be regulated by the 
violence of the disease, the state of the patient's constitution, and the 
stage of the complaint. 

The old method of close hot rooms, warm clothing, and hot drinks, 
may be considered as abolished since the time of Sydenham ; experience 
having shown that cool, well-ventilated apartments, comfortably cool 
bedclothes, and cooling drinks, are much more pleasant and successful. 

As we cannot prevent the disease from running its course, our aim 
must be to mitigate such symptoms in each stage as may threaten to 
become dangerous. 

During the stage of incubation we can do little or nothing beyond 
having recourse to the ordinary hygienic rules, but during the second 
stage we may endeavor to moderate the febrile excitement. 

When we have any reason to suspect the patient of having taken 
smallpox, if the fever be moderate there is little to be done beyond 
confinement to bed, cool drinks, and a dose or two of purgative medi- 
cine. 

1 Mai. cle la Peau, vol. i. p. 539. 

a Report of Cork St. Free Hosp., Dublin Journal, 1844-5, p. 45. 



666 SMALLPOX. 

But, suppose the fever to be intense, are we to resort to bloodletting? 
Not for that simply, it would appear. At the commencement an emetic, 
afterwards purgatives and cool drinks, with low diet, will answer the 
purpose, unless some complication should declare itself. 

If there be evidences of much cerebral excitement, of pulmonary, or 
gastro-enteric inflammation, &c, and especially if the type of the epi- 
demic be inflammatory rather than typhoid, we must have recourse to 
bleeding from the arm, or the application of leeches. For this we have 
the sanction of the highest authority, though others have objected. 

Dr. Gregory remarks : " I can give you no rules as to the quantity 
of blood to be drawn. Consider the circumstances of each case, and be 
guided by them. Your object is to unload and relieve the lungs, the 
liver, or the brain. Whenever, therefore, these organs are gorged and 
their functions impeded by a load of stagnant or inflamed blood — when 
intense headache, extreme irritability of the stomach, oppressed breath- 
ing, with a full, laboring pulse, give evidence of such general or local 
congestion ; draw blood, and let the quantity drawn be such as to re- 
lieve the urgent symptoms. In some cases, when headache predominates, 
with suffusion of the eyes, leeches applied to the temples afford all the 
relief which is required to take off the strain from the vessels." 1 

Saline effervescing draughts, small doses of James's powder, &e., by 
promoting the cutaneous secretion, will moderate the heat of the skin. 

Nitrate of potass has been recommended as a refrigerant by Henke 
and others. Lemonade made with cream of tartar is a pleasant beve- 
rage ; and both these salts act upon the kidneys beneficially. 

We must take care, however, not to carry the cooling regimen to 
excess, or the patient may be attacked by some organic disease ; and 
in giving acid drinks we must have consideration for the state of the 
bowels. 

Dr. Condie recommends that the hair should be cut short, not merely 
as a matter of cleanliness, which it will promote, but as diminishing the 
tendency to cellular inflammation of the scalp, sore eyes, &c. 

If there be much soreness of the mouth and fauces, an acidulated 
gargle will be useful; if the child be too young, we must use honey with 
a slight proportion of borax, or sponge the mouth with an acidulated 
lotion. 

910. As soon as the eruption appears the fever generally subsides, 
and if there be no complication, we shall scarcely need to interfere be- 
yond assuring ourselves of the state of the bowels, continuing the anti- 
phlogistic regimen, and guarding against cold. 

If there be any organic disturbance or inflammation, then our treat- 
ment must be carefully directed for its relief, with such modifications as 
the presence of so severe an eruptive disease may impose. 

911. During the stage of maturation or suppuration, if the disease 
be mild and discrete, there will be little for us to do. 

The cold drinks may be continued, and some slight stimulant allowed 
if the patient be weak, such as wine whey, weak wine and water. 

Gargles will still be necessary in most cases, or a linctus if the in- 

1 On Eruptive Fevers, p. 83. 



SMALLPOX. 667 

fant be young. Small doses of camphor or ammonia are sometimes 
beneficial ; and in consequence of the irritation and restlessness pro- 
duced by such an extent of suppurating surface, it may be advisable to 
give an anodyne, so as to quiet the nervous system and procure sleep. 

From the relief aiforded by a critical diarrhoea we are advised to the 
liberal use of purgatives at this period. 

In severe cases of confluent smallpox, where the fever assumes a 
typhoid type, stimulants must be freely given during this stage. Wine 
or brandy, chicken-broth or beef-tea, must be given according to cir- 
cumstances, and in such quantities as the case may demand. 

Camphor, ammonia, musk, &c, may also be administered with benefit. 

In petechial or hemorrhagic cases vegetable or mineral acids have 
been recommended, as sulphuric, chloric, hydrochloric, and lemon-juice, 
either alone or in combination with quinine. 

Dr. Gregory thinks that these cases admit of no essential relief from 
medicine. 

The complications which are so apt to arise at this period will require 
great watchfulness to detect them, and great skill in the adaptation 
of the suitable treatment which I have heretofore detailed. We must 
have regard not merely to the organ affected and the intensity of the 
attack, but to the present condition of the child, and the probable course 
of the disease. 

912. The tumefaction of the face and state of the eyes will require 
great attention. Fomentations of warm water, decoction of poppy heads, 
or the vapor of warm water, will be very soothing. 

If the eyelids are closed, in addition to bathing them carefully and 
frequently, warm water should be thrown into them by means of a 
syringe, so as to cleanse them from the discharge. 

Acetate of lead dissolved in water or a decoction of poppy heads is a 
very nice application, provided there be no ulceration of the cornea ; if 
there be it will leave a white spot, which nothing will remove. On this 
account it should not be employed unless we can ascertain the state of 
the cornea. 

In order to prevent the face from being marked, it has been proposed 
by Velpeau and Meyrick to touch the pustules with nitrate of silver 
after removing the epidermis ; and Rilliet and Barthez state that, 
though painful, it is effectual in preventing cicatrices. MM. Serres and 
Oliffe propose to pencil the eruption with a strong solution of nitrate of 
silver (gr. xv to gr. xlv to the ounce) before it assumes the pustular 
form. 

Medavaine employed frictions with sulphur ointment ; Dr. Steward- 
son and others the application of mercurial ointment, and keeping the 
patient in a dark room. Of the latter Dr. Condie and Dr. West speak 
favorably. 

Dr. Crawford, of Montreal, and Dr. Jackson, of U. S. America, state 
that they have obtained favorable results from pencilling the eruption 
with tincture of iodine. 

913. During the stage of desiccation, after the secondary fever has 
subsided, it will be necessary to support the strength by a gradually 
improving diet, wine tonics, &c. Much care must be taken that the 



668 VACCINIA. 

patient shall not take cold, or by imprudence expose himself to the 
secondary affections which come on at this time. 

A warm bath, repeated twice a week, will be of use not merely in 
cleansing the surface and in allaying the itching, but in so restoring the 
skin to its natural condition that the troublesome rheumatic affections 
and abscesses may be prevented. 

As the itching at this period is very troublesome, we must adopt some 
means to relieve it, and to restrain the child from adding to the dis- 
figurement by scratching or picking itself. Cold cream, oil, or sperma- 
ceti, are recommended ; but the best remedies I know are zinc cream, 
the black wash, or a decoction of poppy heads with sugar of lead. 

The only prophylactic treatment is either inoculation or vaccination : 
the former is prohibited by law in these countries, as it would be a 
foolish risk where a better and safer remedy is at our command. I 
have, therefore, not entered into the subject ; but those who are anxious 
for information will find sufficient in a collection of pieces on the 
subject published in 1768, in Dublin, or in Dr. Thompson's work on 
smallpox. 



CHAPTER V. 

VACCINIA. — COWPOX. 



914. If he who "makes two blades of grass grow where one grew 
before" be a benefactor to mankind, what shall we say of him whose 
genius has stayed one of the most desolating plagues of mankind, who 
has been the means of saving millions of human lives, who has con- 
tributed to the preservation of families, who has enlarged and rendered 
more secure the social circle, who has given permanency to holy ties, who 
has multiplied the manhood of nations, and added to their true wealth 
and strength ? It is trifling with realities to talk of the glory which 
involves destruction, in presence of this greater glory of preservation. 
In the long list of earth's benefactors, very few, if any, will take prece- 
dence of Edward Jenner, when the true importance of things is clearly 
discerned. 

After having learned in the last chapter the frequency and destruc- 
tive extent of the epidemics of smallpox, its proportionate and absolute 
mortality, we are well prepared for appreciating the value of the remedy 
now to be considered. 

It appears that in certain districts of dairy farms it had been observed 
that the cows were subject to an eruption upon the teats, and that the 
hands of the milkers frequently took the eruption from these cows — 
were inoculated in fact. Those who did so regarded themselves as 
secure from the smallpox, and I believe were so. But although this fact 
was open to the investigation of every one, nay, though it had been 
pressed upon the notice of the provincial medical men, they could or 
would see nothing in it. 



VACCINIA. 669 

In the year 1770, when Dr. Jenner went to study in London, he 
mentioned this popular opinion to John Hunter ; and on his return to 
Berkeley, in Gloucestershire, he applied himself to the investigation of 
its .truth or falsehood. 

Nothing can he more interesting and instructive than the record of 
his labors — the patient, unwearied industry, the energy in overcoming 
obstacles, the acuteness in distinguishing differences, the candor, and 
honesty, and strength of mind in dealing with opponents — all convey a 
lesson by which we may well profit, and the relation of which I should 
gladly undertake, for the benefit of my junior readers, if I had space 
and time. As it is, I must content myself by saying, that having satis- 
fied himself of the truth of the popular opinion, he conceived the grand 
idea of propagating the cowpox by inoculation, as a preventive of small- 
pox. This was about 1780, and he continued his inquiries yet sixteen 
years longer before he made his first experiment. On the 17th of May, 
1796, a boy was vaccinated, and tested with smallpox on the 1st of 
July the same year, and found unsusceptible. This was the hour of 
triumph for Jenner, and the reward of near thirty years' labor. The 
rest of his life was spent in furthering the spread of vaccination by his 
personal influence, writings, &c. ; and he sunk to rest with the con- 
sciousness of having been made a blessing to all mankind. 

I shall not enter into any detail as to the subsequent history of vac- 
cination, the objections that were made, the obstacles that were raised, 
nor into the successful efforts of its advocates and friends. It is sufficient 
to know, as all do now, that it did triumph, that it has spread from 
nation to nation throughout the civilized world, and that it has in these 
countries the sanction of law ; for, by an Act of Parliament passed in 
1840, propagating smallpox by inoculation is prohibited and vaccination 
prescribed to all. 

915. Dr. Gregory thus describes the regular course of cowpox : " On 
the third day from the insertion of the virus, the wound will be per- 
ceived red and elevated. By aid of the microscope, the efflorescence 
surrounding the inflamed point will be distinctly perceived, even on the 
second day. On the fifth day the cuticle is elevated into a pearl-colored 
vesicle, containing a thin and perfectly transparent fluid in minute 
quantity. The shape of the vesicle is circular or oval, according to 
the mode of making the incision. On the eighth day the vesicle is in 
its greatest perfection ; its margin is turgid and sensibly elevated above 
the surrounding skin. In color the vesicle may be yellowish or pearly. 
The quantity of fluid which it contains will be found to vary very much. 
When closely examined, the vesicle will exhibit a cellulated structure. 
The cells are eight or ten in number, by which the specific matter of 
the disease is secreted. The vesicle possesses the umbilicated form 
belonging to variola. On the evening of the eighth day (counting from 
the day on which the incision was made) an inflammatory circle or 
areola commences at the base of the vesicle. The skin becomes tense, 
red, and painful, for a considerable extent around. The figure of the 
areola is perfectly circular. In some cases the subjacent cellular mem- 
brane participates in the inflammatory action, and occasionall}'- the 
glands of the axilla swell. The areola continues to advance during the 



670 VACCINIA. 

ninth and tenth days. On the eleventh day it begins to fade, leaving 
in its decline two or three concentric circles of a bluish tinge. The 
vesicle by this time has either burst spontaneously or been opened by 
the lancet of the surgeon. Its contents now become opaque. The 
vesicle itself begins to dry up, and a scab forms of a circular shape, 
and a brown or mahogany color. By degrees this hardens and blackens, 
and at length, between the eighteenth and twenty-first day, drops off, 
leaving behind it a cicatrix of a form and size proportioned to the prior 
inflammation. A perfect vaccine scar should be of small size, circular, 
and marked with radiations and indentations. These show the charac- 
ter of the primary inflammation, and attest that it had not proceeded 
beyond the desirable degree of intensity. Many of the perfect scars 
disappear entirely as life advances." 1 

There is very little constitutional disturbance attendant upon vac- 
cination; occasionally, after the seventh or eighth day, the child becomes 
restless, uneasy, and feverish, with loss of rest and diminished appetite. 
This disappears after lasting for a few days. Now and then we see a 
child suffer during the entire course of the disease; and on the other 
hand, many children go through it with no fever at all. 

916. Modifications and Irregularities. — Let us first notice those 
cases in which their deviations do not impeach the validity of the vac- 
cination. 

I. The vaccine vesicle may be tardy in its appearance ; in some cases 
it shows no appearance until the sixth or eighth day, and then runs 
through its course ; in other cases the delay seems to be in the matura- 
tion; the inflamed spot appears at the proper time, but the vesicle is 
not complete until the tenth or twelfth day, or even longer. 

Dr. Labatt has met cases where no inflammation occurred till the 
twelfth day ; Mr. Bryce, others deferred a fortnight ; Mr. Pearson, one 
case, where it did not appear for twenty days ; Mr. Ring, in one in- 
stance, saw no appearance before the forty-sixth day. 

We can understand that a co-existing disease, such as measles, scar- 
latina, diarrhoea, &c, may modify the course of vaccinia ; but in many 
cases no such cause exists, and it is quite impossible to explain the 
delay. 

II. In some cases, on the first appearance of the vesicle, it gets rub- 
bed, or the child scratches off the head, and the character of the vesi- 
cle is changed. It loses its proper form and is more conoidal ; its con- 
tents, too, are rather thicker and more yellow than usual, and it has 
more the appearance of a pustule. There is an areola around the base, 
and the scab is small and drops off prematurely. 

" When all the previous appearances have been well marked, it will 
occasionally happen that at the desiccating period pus shall be formed." 
"When any pus is formed, it is probably the effect of local irritation. 
If the crust be torn off, or mechanically injured, an ulcer is often found, 
which frequently, especially in scrofulous constitutions, proves difficult 
of cure." 2 

in. In other cases the inflammation is very intense; the areola occu- 

1 On Eruptive Fevers, p. 189. ? Labatt on Covrpox, p. S3. 



VACCINIA. 671 

pies two or three times its usual extent, is of a deep red color, and re- 
sembles erysipelas. The vesicle, instead of drying, is converted into 
an ulcer, involving the entire thickness of the cutis, and leaving behind 
a deep pit, as large as a sixpence or shilling. 

In these cases the suffering is considerable, and the fever sometimes 
runs very high. I have noticed this occurrence particularly in children 
beyond ten years of age, and young persons, and I attribute it to rub- 
bing during sleep for the relief of the itchiness. 

Dr. Labatt mentions that he has met with cases of diffuse inflamma- 
tion following vaccination, and Dr. Osbrey has given two cases of a 
very formidable character, the arm swollen and inflamed, the vesicle 
turned into a dark slough with the surrounding parts livid and appa- 
rently gangrenous, great fever in one case and stupor in the other. 1 

IV. During the course of the vaccine vesicle, we may sometimes 
observe a lichenoid eruption on the child's body, with crops of vesicles 
here and there. It apparently arises from the peculiar irritability of 
the skin in some infants, and it may occasion uneasiness to the parents, 
for which, however, there is no ground. Dr. Labatt has referred to 
several similar examples. 

917. There are other deviations from the normal course of vaccinia, 
which are either unsatisfactory or quite inefficacious. 

I. The same vaccine virus may succeed with one child and fail with 
another, without any appreciable cause. Many children require to be 
vaccinated several times before we succeed; others, though rarely, resist 
every attempt. 

Mr. Bryce vaccinated a child ten times and failed; Mr. Elkington 
was himself inoculated for smallpox four times, and three times for cow- 
pox, but in vain. 

I have vaccinated children seven times before the infection took, and 
in obstinate cases I allow a considerable interval to elapse before repeat- 
ing the vaccination. 

In other cases, doubtless, the failure may be accounted for either be- 
cause the lymph has been taken from a spurious vesicle, or at too late 
a period, or upon a rusty lancet, or it has been injured by heat, exposure, 
or moisture, or on account of some coincident disease. 2 

II. Occasionally we find the inflamed spot on the third or fourth day 
as it ought to be in appearance, but instead of progressing in the usual 
manner, a small acuminated vesicle forms, without or with very slight 
areola, and soon dries up into a minute scab, which falls off in a day or 
two. 

in. "Sometimes the insertion of vaccine lymph is followed by a 
slight inflammation, gradually increasing to the fifth or sixth day, when 
a pustule is formed containing opaque matter. Every now and then the 
inoculated part proceeds regularly for a few days, when a watery dis- 
charge takes place, followed by a crustaceous sore; and about the 
eleventh day the part is usually covered by a dark-colored crust. I 
should distrust such cases." 3 

1 Dublin Journal, vol. xxv. p. 137. 2 Monro on Smallpox, &c, p. 109. 

3 Labatt on Cowpox, p. 88. 



672 VACCINIA. 

IV. Dr. Labatt lias laid down the characters of spurious cowpox so 
succinctly that I cannot do better than quote them: "There are two 
kinds of spurious vesicles : the first bears a strong resemblance to the 
true in several respects; its edges are commonly elevated, its contents 
nearly limpid, and it continues the usual time ; but it commences with 
a creeping scab, of a pale brown, or amber color, making a long, slow 
progress, sometimes unattended by any efflorescence ; the vesicle is 
more transparent, and the pellicle is generally thinner and easily torn. 
This Dr. Jenner has particularly noticed, and he ascribes it to the virus 
used for inoculation having been exposed to a degree of heat capable of 
decomposing it. 

" The second kind appears early and increases rapidly ; is elevated in 
the centre, and globular, with more or less of the appearance of a com- 
mon phlegmon ; and when punctured, there issues opaque fluid, re- 
sembling what is produced in any other festering sore. It is more easily 
ruptured ; at the sixth or seventh day it generally runs into a perfectly 
purulent state. The areola is irregular or notched, resembling a large 
blotch ; has a fiery or livid aspect ; is not shaded off into the surround- 
ing skin ; and, as Dr. Cappe observes, seems rather to be under than 
upon its surface, while, at the same time, it is less extensive, nor is the 
hardness around it so evident. A ragged scab prematurely covers the 
vesicle, or, when the black crust should form, a yellowish sore appears, 
drying and breaking out again, with an oozing from under it. Imper- 
fect vesicles are, in general, smaller and more globular than the true 
vaccinia ; they have not the turgid, convex margin, but a somewhat 
puckered base, appearing to slope off into the surrounding skin ; they 
have not a cellular structure ; contents not a clear, transparent lymph, 
but a straw-colored, opaque, or purulent fluid ; the areola not defined, 
nor of so vivid a rose tint, but ragged and diffuse, appearing about the 
seventh or eighth day, or earlier, on the fifth or sixth, of a dark red 
color, with less hardness than the true areola, and disappearing sooner ; 
the succeeding crust is smaller, of a light brown or amber color, irregu- 
lar, and friable, forms earlier, separates sooner, and leaves an indistinct 
and not pitted cicatrix." 1 

v. Smallpox and cowpox may sometimes exist together, without any 
sensible modification of either, or they may each restrain or modify the 
other. If the variola have preceded the vaccinia, and the fever be high, 
the latter will generally be, as it were, blighted. 

918. In an enormous majority of cases, the vaccine vesicle not only 
runs its proper course, but vaccination is successful, and the child is pro- 
tected against the smallpox. We have seen that the practice of inocula- 
tion was attended by a greatly diminished mortality, but not to be com- 
pared with the immunity conferred by vaccination. Notwithstanding 
the prevalence of natural smallpox and (until lately) of inoculation, it 
has been found that the mortality has gone on diminishing since the 
time of Jenner ; and it is hardly too much to attribute, with Dr. Monro, 
the great increase of the population which took place between 1801 and 
1811, compared with the previous ratio, to the lives saved by vaccina- 
tion. 

1 Labatt on Cowpox, p. 90. 



VACCINIA. 673 

919. I has, however, been supposed that its protective power may be 
exhausted in time, and certainly there is so much evidence in favor of 
this opinion, that in a number of cases where a genuine vesicle was 
formed in childhood, smallpox or varioloid has occurred in after life. 
Whether the number of such cases is increasing I cannot say, but for 
many years they were not numerous. In the Report of the College of 
Surgeons it is stated that of 164,381 persons vaccinated by members, 
only 56, or about 1 in 3000, were afterwards affected with smallpox. 1 
Dr. Monro thinks that such cases are more frequent than here stated. 
In Dr. Baron's Report I find that, between 1825 and 1832, 86,646 
patients were vaccinated at the National Vaccine Establishment, and 
of that number only two deaths from smallpox after vaccination are 
mentioned. Dodd reports 201 cases of smallpox in the year 1837, of 
which 114 were after reported vaccination; 91 cases were mild, 23 
severe, and 2 fatal. At the Royal Military Asylum, Chelsea, between 
1803 and 1833, of 2533 who had smallpox before admission, 26 had 
smallpox again, and 3 died ; of 3688 who were vaccinated before or 
after admission, 27 caught smallpox, and none died. 2 

It is to meet such cases that certain persons have recommended re- 
vaccination after the interval of a number of years, or periodically every 
seven years. In Prussia several extensive revaccinations have been 
practised, and even among those who took it, some few cases of small- 
pox occurred. The late Dr. Labatt, whose high standing and experience 
all will admit, objects to these revaccinations as being unnecessary, con- 
sidering the small proportion of variola after vaccination, and also as 
not being valid as a test of the former vaccination, or as a safeguard for 
the future. 3 

During the winter of 1849-50, smallpox was epidemic in Dublin, and 
most of us witnessed cases of persons taking it, in whom vaccination had 
been successfully performed during infancy. I met with several such 
cases, but I did not meet with a single such case, nor had those profes- 
sional brethren whom I consulted, under 16 years of age. So far as 
this goes, it is an evidence undoubtedly for the exhaustion of the pro- 
tective effects of the virus after a certain time, and an argument for 
revaccination. 

There are some questions relating to revaccination which deserve a 
further investigation. Of those revaccinated, a large number succeed 
well — it is certain that they were previously obnoxious to smallpox. A 
certain number take it in a modified form ; is that because of their pre- 
vious vaccination ? and are we to infer their security from smallpox ? 

Is there any doubt about their security with whom re-vaccination fails 
altogether ? 

The late Dr. Fisher, of Boston, who had devoted much attention to 
this subject, arrived at the following conclusions from extensive statisti- 
cal researches : — 

1. " That one single and perfect vaccination does not for all time and 
in all cases deprive the system of its susceptibility of variolous disease, 

1 Monro on Smallpox, p 147. 2 Labatt on Cowpox, p. 14. 

3 Ibid., p. 141. 

43 



674 VACCINIA. 

2. That one or more revaccinations do ; and that consequently a phy- 
sician should recommend revaccination, when questioned as to its ne- 
cessity." 1 

Or, entering more fully into the question, he concludes that, " 1. A 
portion of vaccinated persons are protected from smallpox through life 
by one vaccination. 2. An indefinite number are protected only for a 
certain period of time. 3. The length of time they are thus protected 
is undetermined. 4. Some individuals require to be vaccinated a num- 
ber of times during life. 5. The system is protected from variolous con- 
tagion when it is no longer susceptible of vaccine influence, as tested by 
revaccination. 6. The cowpox virus does not seem to be more effica- 
cious than the human vaccine virus in its prophylactic virtues, and the 
influence of the vaccine virus does not seem to be diminished by the 
number of its removes from the cow or passages through the human sys- 
tem. 7. The appearances of vaccine cicatrices furnish no indication that 
the system may or may not be again influenced by repeated vaccina- 
tions. 8. A plurality of vesicles have no more effect in rendering the 
system less obnoxious to the influence of revaccination than a single 
vesicle has. 9. The lapse of time from the period of primary vaccina- 
tion to that of revaccination has some, though but little effect in pre- 
paring the system to be further influenced by the vaccine virus. 10. 
The age of puberty tends in a degree to destroy the effect of primary 
vaccination. 11. The virus contained in vesicles resulting from re- 
vaccination has the same anti-vaccine and anti-variolous power as that 
which is the product of vesicles produced by the primary vaccination." 
I may also refer my readers to Dr. Alex. Knox's valuable papers 2 
and the conclusions elaborated by M. Craninx, 3 for the result of their 
observations in favor of vaccination and revaccination. 

9^0. But granting that a certain number of such cases occur, or even 
supposing them far more numerous than they are, it ought not to shake 
our confidence in vaccination, considering the millions who pass through 
life with perfect immunity from smallpox; nor would it prove that even 
in those cases vaccination was of no use, for these exceptional cases sel- 
dom or never take the genuine variola, but that modified form of it which 
is called varioloid — an infinitely milder disease, and one almost never 
involving either danger or disfigurement. 4 

921. There is still a very interesting question remaining, viz : what is 
cowpox, and what relation does it bear to smallpox ? Are they simply 
different and incompatible diseases; or is the one a substitute for the 
other, having some relation ; or are they modifications of the same dis- 
ease, and identical in nature ? Dr. Jenner thought the latter, and fur- 
ther experiments have confirmed his opinion. 

A disease resembling variola prevails among animals during epidemics 
of smallpox; this can be communicated from one animal to another by 
inoculation, and be thus rendered milder, that it may be communicated 
to human beings, producing a mild disease. On the other hand, human 

1 Trans, of the American Med. Association, vol. iii. p. 73. 

2 London Journal of Medicine, Dec, 185U. 

3 Gazette Med. of Paris, No. 27. 

4 Lancet, March 27, 1852. 



VACCINIA. 675 

smallpox may be communicated to the cow by inoculation, producing a 
mild form of the disease ; and if matter be taken from these pustules, 
and a human being inoculated thereby, a disease identical with cowpock 
will result: " thus irresistibly proving," as Dr. Baron observes, " Dr. 
Jenner's fundamental proposition, that cowpock and smallpox are not 
bond fide dissimilar, but identical, and that the vaccine disease is not the 
preventive of smallpox but the smallpox itself; the virulent and con- 
tagious disease being a malignant variety." 

922. Diagnosis. — The characters of a true vaccine vesicle, are, that 
it begins to appear on the third or fourth day after the insertion of the 
virus ; that it increases for three or four days more, until on the eighth 
day it is round or slightly oval, depressed in the centre (like a pustule), 
with elevated edges, and containing clear, transparent lymph, which 
becomes afterwards opaque ; that it has a well-marked areola ; and 
that a brown circular scab forms and falls oil', leaving a circular depres- 
sion. 

Dr. Labatt remarks : " I have seen the areola very faint, but seldom 
entirely absent, nor should I be satisfied with any case unattended with 
areola and the normal circumscribed hardness, which I consider indica- 
tive of constitutional vaccine affection ; and I know of no other certain 
proof of perfect vaccination." 1 

Mr. Bryce, in 1802, proposed a test of the validity of the vaccina- 
tion, founded on the fact that when fresh vaccine virus is reinserted on 
the fourth, fifth, or sixth day from the first vaccination, but not later, 
the vesicles of the second form rapidly, and are hurried forward in 
their course, so as to overtake the first, and to maturate and scab at 
the same time. 

This plan was very popular at first, but seems now to have fallen 
into disuse. Dr. Labatt, however, is quite in favor of this test. He 
says : " When correctly conducted, it will, in my opinion, give eveiy 
security against future attacks of smallpox which it is in the power of 
vaccination to afford ; but if the second inoculation be postponed be- 
yond the sixth or beginning of the seventh day, in the ordinary course 
of the affection, the characteristic test will not be obtained," &c. 2 Dr. 
Gregory thinks that if there be any doubt of the perfect success of the 
first vaccination, it is better to repeat it after an interval of months or 
years. 

928. Mode of Operating. — Before proceeding to the actual opera- 
tion, let me say a word about the lymph, and the best method of select- 

I. First, then, we should be very particular in taking the matter 
from healthy children only. It is a popular belief that various diseases 
and certain morbid conditions of the body may be transmitted through 
the medium of vaccine lymph, and although I do not believe this, yet I 
would never outrage a prejudice of the kind. Healthy children are 
sufficiently common, and it is a satisfactory assurance to a parent that 
she has no injury to fear from this source for her child. 

n. The day on which lymph is ordinarily taken is the eighth, but it 

1 On the Compos, p. 81. 2 Ibid., p. 102. 



676 vaccinia. 

may be taken earlier and used successfully, and it will answer at a later 
period. Even the scabs, when powdered and dissolved in water will 
succeed, but they are not so certain. Dr. Gregory's experience is thus 
stated : " The younger the lymph is the greater its intensity. The 
lymph of a fifth day vesicle, when it can be obtained, never fails. It 
is, however, equally powerful up to the eighth day, at which time it is 
also most abundant. After the formation of areola, the true specific 
matter of cowpox becomes mixed with variable proportions of serum, 
the result of common inflammation, and diluted lymph is always less 
efficacious than concentrated virus. After the tenth day the lymph 
becomes mucilaginous and scarcely fluid, in which state it is not at all 
to be depended on. Out of a dozen incisions made with such viscid 
lymph, not more than one will prove effective. The scabs of cowpox 
ground to powder, and moistened with lukewarm water to the con- 
sistence of mucilage, will sometimes reproduce the disease in all its 
purity." 1 

But the lymph may Vary in purity in different persons at the same 
period ; every vesicle does not necessarily contain equally efficacious 
lymph. It is more effectual from infants than from adults, and from 
primary than from secondary vaccinations. 

in. The usual methods of conveying the lymph are on the point of a 
lancet, on small-pointed slips of ivory or quill, or on small squares of 
glass. The first is undoubtedly the best, but it is even better when 
we have it in our power to vaccinate one child direct from the arm of 
another. 

iv. The incisions are to be made with the point of a lancet inserted 
into the skin, or a few scratches made upon the surface. Blood must 
be drawn, but too much is inconvenient, as it dilutes the lymph, and is 
apt to run down the arm. 

As to the number of vesicles to be raised, different opinions have 
been held. At an early period one vesicle was considered sufficient ; 
then three, four, or six were recommended. Some of the Germans 
insist on twenty or thirty, as they hold that no reliance can be placed 
upon the vaccination unless some constitutional effect be produced. 

Dr. Gregory advises that five vesicles should be produced. 

In this country it is, I believe, the custom generally to make two 
punctures, nor is it found less effectual than five. 

For some years I have only made one, on account of the severe in- 
flammation which sometimes results from two or more, nor have I had 
any reason to suppose that my object was not as completely attained. 

1 On Eruptive Fevers, p. 195. 



CEDEMA OP THE CELLULAR TISSUE. 677 



CHAPTER VI. 

(EDEMA OF THE CELLULAR TISSUE. — SCLEROMA. 

1. The disease of which I propose now to treat, osdema of the cellular 
tissue, cannot fairly be classed among the diseases of the skin ; but, as 
no other place in the volume is more suited for it, I have ventured to 
insert it here. 

The name given to it in this country is " hide-bound, or skin-bound 
disease," and most frequently by French writers, " induration of the 
cellular tissue;" but, as this is quite incorrect, I have adopted the one 
which expresses correctly its nature, and which is preferred by Billard 
and Valleix. It is a disease rare in these countries, and still more rare 
in private practice, but not uncommon in the foundling hospitals on the 
continent, and consequently it is to the researches of continental physi- 
cians that we are indebted for the most accurate account of the disease. 

From the year 1808 to 1811, 645 cases occurred in the Hospice des 
Enfans Trouve's at Paris, and in the year 1826, 240 cases. On an 
average, 1 in every 25 infants admitted are attacked by the disease 
a few days after birth, and not more than 12 in 100 recover. 

From the year 1828 to 1851, 53 cases occurred in the Lying-in Hos- 
pital at Stuttgard, 10 being born at the full term of gestation, and 43 
prematurely. The disease prevailed most extensively in the years 
1849-50, during which time puerperal fever was epidemic in the hos- 
pital. 1 

2. Symptoms. — The attack commences shortly after birth, generally 
from the first to the fifth day, and it shows itself sometimes by a livid 
redness over the body, or by a circumscribed hard spot on one of the lower 
extremities, over which it spreads, and gradually ascends to the trunk, 
and from thence to the arms and face. The anterior part of the chest 
and the back are generally affected the last. The side on which the 
disease commences is generally more swollen than the other. That the 
swollen parts pit on pressure, there can be no doubt ; but when the dis- 
tension is extreme, a strong pressure of the finger may be required, and, 
when slight, the indentation soon disappears. This may have given 
rise to the opinion of MM. Auvity, Blanche, and Denis, that the tissues 
do not preserve the impression of the finger. 

According as the cellular tissue becomes infiltrated, the limb or the 
trunk swells, and acquires a firm or hard feel, as though the entire 
tissues were indurated, and at the same time the temperature diminishes 
very considerably. M. Roger says that the coldness even precedes the 
swelling. M. Valleix met with but one exception : most frequently the 

1 Archives Gen. de Med., May, 1853, p. 539. 



678 (EDEMA OF THE CELLULAR TISSUE. 

coldness commences in the lower extremities, but sometimes in the abdo- 
men. In the last stage of the disease, the entire body is so cold as to 
be unpleasant to the touch. It is extremely difficult to warm the 
patient, and, if we succeed, the body rapidly loses its heat. 

After a short time a change takes place in the color of the surface ; 
the lividity diminishes gradually, and is succeeded by a yellow tinge, 
especially in the face, which deepens towards the termination of the 
disease, and around the mouth is mixed, as it were, with a livid tinge. 
The feet ordinarily, and sometimes the hands, preserve their reddish- 
blue color. 

Until the effusion becomes considerable, the skin is quite movable, 
and can be gathered into folds, but of course this looseness is by de- 
grees lost, and at length the whole of the tissues seem solidified to- 
gether, which led Underwood to suppose that the skin was as it were 
adherent to the bone. 

The general state of the child is one of great weakness, its sensi- 
bilities are all diminished, its eyelids are almost always closed, and in 
the more serious cases, it will lie in a stupid, half insensible state, and 
die without a sign. When disturbed much, it is uneasy, and makes some 
efforts with its limbs, and if distressed it will cry, and the voice is quite 
peculiar. As M. Valleix observes, it is sharp, broken, and very 
feeble, often stifled or muffled. 1 M. Auvity was right in saying that a 
physician who once heard will always recognize it. But this charac- 
ter is noticeable only at first ; by degrees the cry becomes stronger, 
deeper, and at length resembles that of healthy infants. In very slight 
cases, the voice is but little changed, but only in one serious case did 
M. Valleix find it pure in tone, and pretty strong. 

It has been supposed that this peculiarity of voice arises from oedema 
of the glottis, and of the chordce vocales, but this is sufficiently dis- 
proved by the fact that M. Valleix only met one case in which the 
chordas vocales were ceclcmatous. He considers that it depends upon 
the difficulty, feebleness, and incompleteness of the respiration. 

M. Duges, and others, mention the occurrence of spasmodic move- 
ments, and even of trismus and opisthotonos. M. Leger denies their 
existence, and M. Blanche and Mr. Elsasser 2 mention having observed 
a degree of agitation of the limbs, but not in the least resembling con- 
vulsions. However, as M. Auvity found in some cases, a degree of 
effusion in the arachnoid, it is possible that convulsive movements may 
occur, although they are not dependent upon the affection of the cellu- 
lar tissue. M. Valleix mentions that he never saw either convulsions 
or tetanus ; when much disturbed, the child made efforts at flexion of 
the limbs. He never saw the rigid, stiff condition stated by M. Duges, 
in which the child could be raised like a log, by the head or the feet. 

The state of the respiration is peculiar. M. Blanche mentions its 
being rapid, 3 but M. Valleix found it, on the contrary, much slower 
than usual; inspiration is sudden and short, so that the chest is in- 
completely dilated, but expiration is very gradual, so that the interval 

1 Chirurgie des Mai. des Enfans. 2 Arch. Gen. de Med., May, 1853, p. 542. 

3 Essai sur l'endurcissement du tissu cellulaire chez les nouveaux-n6s, These, 1834. 



(EDEMA OF THE CELLULAR TISSUE. 679 

between the inspirations is considerable. If the child be stripped, the 
abdominal movements will be found to be very slight, in some cases 
scarcely perceptible, if the child do not cry, and now and then we 
observe a great effort at inspiration, after which the parietes of the chest 
resume their immobility. 

In one case, M. Valleix found an interval of from 10 to 12 seconds 
between the inspirations, and in four others 16 or 18 inspirations only 
in the minute. 

"In 18 cases whose bodies were subsequently examined, there was 
dulness on percussion in two from the beginning, in one on the left side, 
below and behind ; in the other on the right side, above and behind. 
Three times dulness came on in the course of the disease, in two on the 
right side and in one on the left. In the first cases, the dulness re- 
sulted from non-dilatation of the lung; in the latter from congestion 
and induration. In my latter cases, pneumonia was much more fre- 
quent, since it occurred in four out of six cases; it was always cha- 
racterized by cough, 'dyspnoea, and dulness, the bronchial souffle and 
bronchophony were heard but three times. These symptoms appeared 
in one case at the same time as the oedema, but in all the others at least 
two or three days after the commencement." 1 

The pulse is generally slower than usual, from 60 to 72, or about 80; 
according to Elsasser, so weak and small as scarcely to be felt; indeed, 
if the oedema be considerable, that combined with the extreme weakness 
will probably render it impossible to count the pulsations. The heart's 
action is weak also, but generally more distinct than the arterial. 
The digestive system seems to partake of the general torpor, the child 
shows little or no wish for either food or drink; the belly is soft, in 
some cases distended, .but without pain or tenderness; the bowels are 
generally confined; M. Valleix met only one case of diarrhoea. 
Towards the termination, a sero-sanguineous fluid escapes from the 
mouth, as has been remarked by MM. Auvity, Leger, and Valleix, 
which probably M. Denis mistook for vomiting, which rarely or never 
occurs. 

The disease lasts from two to six or eight days. In M. Elsasser's 
cases it terminated on the 1st, 2d, or 3d day, in one case, on the 4th 
day, and very rarely on the 10th or 20th day. 

3. Most of these symptoms are present from the beginning, but in a 
slight degree, and, by degrees, they become more marked as the oedema 
increases. The sleep becomes stupor, the respiration slower, the circu- 
lation more feeble, the cry more stifled, the cold greater and more uni- 
versal. When this state is extreme, the sero-sanguinal fluid escapes 
by the mouth, nose, and sometimes from the eyelids, and death takes 
place calmly, without agitation or convulsions. 

But all cases are not fatal, and in those which have a more favorable ter- 
mination we find the respiration become easier, the circulation stronger, 
and the infant makes an effort to awake, to open its eyes, to drink or 
to suck eagerly. These efforts are repeated from time to time, and 
each time more successfully; the cry has more strength, and we can 

1 Clinique des Mai. des Enfans, p. 618. 



680 (EDEMA OF THE CELLULAR TISSUE. 

perceive the oedema diminish, at first from the eyelids and forearms, 
then the thighs and hypogastrium, then the hands. The legs and feet 
often retain the swelling long after the other parts have resumed their 
natural appearance. For some time the skin hangs loose and retains a 
bluish tinge, but by degrees this disappears. 

4. Pathology. — A series of careful pathological researches have cor- 
rected several errors in the earlier opinions concerning this affection. 
To M. Billard we are indebted for a knowledge of the fact that the cel- 
lular tissue in this disease is not indurated or indeed changed at all, but 
that the hardness is entirely owing to the distension by fluid, and that 
the two are in exact proportion. 1 He has shown, however, that there is 
such a disease as induration of the adipose tissue, occurring just before 
death, with which scleroma may easily be confounded, and this is his 
description of it. " It may exist with or without general infiltration of 
the subcutaneous cellular tissue; the jaws, the thighs, the calves, and 
the back are the most common seats of this induration, and it may 
occur with or without disturbance of the respiration and circulation. 
It ordinarily comes on just before death, or it may be developed after 
death in infants who have been rapidly cut off. If the adipose tissue 
be dissected in these cases, it will be found firm, hard like suet or tal- 
low, quite coagulated, resembling the fat of slain animals." 2 This re- 
ally answers very closely to the description of "skin bound," given by 
Denman, 3 but no such condition is observed in the cases of oedema of the 
cellular tissue, which is a different disease. 

Again, M. Breschet considered that there is something peculiar in 
this oedema of infants, in which it differed from that of adults, and he 
requested M. Chevreul to analyze carefully the serosity infiltrated. He 
states that he found the blood to be in a morbid condition, and that it 
contained two coloring matters not found in the blood of healthy child- 
ren, and besides a matter which rendered the serum coagulable, by 
which he explains the color of the cellular tissue and its induration. 4 
This led M. Billard to repeat the experiments, and to add others, and 
the conclusion at which he arrived is that " the induration of the cellu- 
lar tissue of infants is nothing more than simple oedema perfectly ana- 
logous to that in adults or old persons affected by disease of the lungs, 
heart, or bloodvessels. We find that their limbs occasionally are as 
hard as those of infants in this disease. If in infants the surface is 
very red, it is owing to the habitual congestion of this part." 5 

5. Anclry 6 and Auvity state that the lung is often gorged with blood, 
and yet filled with air ; sometimes, on the other hand, collapsed, black, 
and gangrenous. 

M. Valleix merely observed that these organs were livid, and gave 
issue to a considerable quantity of blood when they were cut into, that 
this blood was accumulated in the most dependent parts. The lungs were 
more or less crepitating, and floated when cut into pieces. In two cases 

1 Mai. des Enfans nouveaux-n6s, p. 490. 2 Ibid. 

3 Underwood's Diseases of Children, p. 273. 

4 Considerations Gen. sur 1' Analyse organique et sur ses Applications, p. 248. 

5 Mai. des Ent'ans nouveaux-n6s, p. 493. 

6 Encycl. Method. Medicine, vol v. p. 548. 



(EDEMA OF THE CELLULAR TISSUE. 681 

only, out of twenty-four, he found true pneumonia, but he also found 
portions of the lungs not yet penetrated by air. Troccon 1 and Duges 
agree with Hulme in attributing this oedema to inflammation of the 
lungs, but the experiments of the former confirm the more recent con- 
clusions of MM. Legendre and Bailly, and others, who have shown that 
the condition of the lung in this disease is not pneumonia, but atelectasis ; 
that the lung is undilated, as in the fcetus which has never breathed ; 
and that it may be inflated after death and made to assume the ordinary 
aspect of that organ. Dr. West observes: "We are, however, certain 
that the appearances, once thought to be the result of pneumonia, are 
in reality due to the unexpanded condition of the lung, and we can un- 
derstand how it may happen, if children be exposed to cold almost im- 
mediately after birth, and then transferred to the ill-ventilated wards of 
a foundling hospital, and there fed with food far other than that which 
nature destined for them, that respiration may be but very imperfectly 
established; that their temperature may consequently fall, and the blood, 
flowing in part through the unclosed foetal passages, may stagnate in its 
course, may give rise to profuse effusions into the great cavities of the 
body, and to an anasarcous swelling of the surface." 

M. Elsasser found lobular pneumonia in one-tenth of his cases. 

In the pleura and pericardium there is a certain amount of serum 
effused, and the heart is filled with dark liquid blood : in a few dases 
there are small coagula. The large arteries and the veins are also full 
of dark-colored fluid blood. 

Serum is also frequently found in the peritoneal cavity. The gastro- 
intestinal mucous membrane rarely exhibits any deviation from health, 
according to MM. Billard and Valleix, although M. Denis mentions 
that he has frequently found small ulcerations in the stomach and intes- 
tines. 

M. Elsasser found hypersemia of the intestines, hypertrophy of the 
liver and of the spleen, hyperemia of the kidneys, with traces of Bright's 
disease : in eight cases peritonitis with effusion, and one purulent infil- 
tration of the mesenteric glands. 

The vessels of the brain are generally much congested, but the con- 
gestion is probably of a passive character. M. Auvity and M. Elsasser 
are the only writers who have found effusion into the cavity of the 
cranium. 

In most of M. Elsasser's cases the membranes of the brain were 
filled with black fluid blood, occasionally there was effusion of blood or 
serum in the lateral ventricles, and in one case the spinal marrow was 
covered with a layer of blood, the arachnoid soaked in it, and the brain 
softened. 3 

6. Complications. — These do not appear to be very frequent, the un- 
dilated condition of the lungs, or portions of them, being the most 
common. In five cases out of twenty-five, M. Valleix found pneumonia, 
and in two more congestion, which was probably inflammatory. Affec- 

1 Sur la Malade connue sous le nom d'endurcissement du Tissu Cellulaire, 1814. 

2 Diseases of Infancy and Childhood, p. 163. 

3 Archives Gen. de Med., May, 1853, p. 513. 



682 (EDEMA OF THE CELLULAR TISSUE. 

tions of the nervous system, and of the digestive organs, jaundice, &c., 
though not quite unknown, are rarely observed, and in one case M. Val- . 
leix saw an attack of erysipelas. 

7. Causes. — Palletta, in 1823, 1 denied the influence of cold in the 
production of this disease, and attributed it to flaccidity of the lungs, 
especially the right, after birth, which he supposes gives rise to conges- 
tion of the lungs and an arrest of circulation, which occasions engorge- 
ment of the liver. M. Valleix objects to this theory as being opposed 
by the experience of Billard, Blanche, Denis, and himself. M.Leger, 2 who 
probably expresses the opinions of Breschet also, enumerates various 
causes, chiefly a disturbance of respiration and circulation, which ren- 
ders the blood more serous, also the non-obliteration of the foetal open- 
ing and the excess of coagulability of the serum. Again, he regards 
jaundice as the first degree of the malady, and lastly he considers that 
in these cases the brevity of the intestinal tube a direct agent. Of the 
first of these causes there can be no doubt, but the latter suppositions 
have either been disproved by more recent researches as matters of fact, 
or we may reasonably doubt their having much to do with the produc- 
tion of this disease. 

M. Denis regards the oedema as resulting from an irritation of the 
cellular tissue coincident with different internal affections, and espe- 
cially with gastro-enteritis. The facts cited by M. Leger, however, 
sufficiently refute this opinion. M. Valleix very justly regards the 
oedema as dependent upon the arrest of the blood, consequently upon 
the disturbance of respiration and circulation, and still more recent 
researches of Bailly and Legendre and others, seemed to prove that 
this disturbance is owing to an undilated condition of a portion of the 
lungs. 

Feebleness of constitution is no doubt the chief predisposing cause ; 
thus, it is very common with premature children, as was remarked by 
Palletta and Valleix, and M. Lediberder saw two children expire a few 
minutes after premature birth with the characteristic respiration. Yet 
it should be stated, on the other hand, that the disease may occur in 
healthy, well-made children born at the full time. 

Cold is undoubtedly the principal exciting cause, as in 177 cases 
mentioned by M. Billard, 106 occurred in the colder months, and out 
of 838 cases given by M. Valleix, 233 occurred in the six winter 
months. 3 The latter eminent observer mentions that children brought 
to the hospital from different parts of Paris, and badly wrapped up ? 
are more liable to the disease than those from the Maternite. 

8. Diagnosis. — There are but two diseases with which oedema of the 
cellular tissue is very liable to be confounded, a. Infantile erysipelas 
with infiltration, but the latter disease commences most frequently in 
the face — the parts are of a deep red color, hot, swollen, and promi- 
nent, and the child is evidently in pain, which is widely different from 
oedema — and the peculiar character of the respiration and circulation 
in the latter disease, is entirely wanting in erysipelas. 

1 Memoir read before the Institute at Milan. 

2 These Inaugurale, Paris. 

3 Clin, des Mai. des Enfans, p. 649. 



(EDEMA OF THE CELLULAR TISSUE. 683 

b. Induration of the Adipose Tissue. — As I have mentioned, this is 
an affection of the last moments of life, generally, and it may be en- 
tirely a cadaveric condition, as has been observed by Underwood, Bil- 
lard, and Valleix. The aspect of the child is different, its color is 
white or yellowish, the skin and subcutaneous tissues appear solidified, 
and the parts attached are generally different. The only symptoms 
common to both are the coldness and the feeble cry. 

9. Prognosis. — The prognosis is serious in all cases, both from the 
nature of the attack and from the weakness of constitution of the sub- 
jects of it. By far the greater portion of the patients die, and for 
premature, or especially weakly infants, one cannot say that there is 
any hope. 

10. Treatment. — M. Billard, to whose researches we are so much 
indebted, thus expresses the results of his observations : " The thera- 
peutic indications which follow from the preceding considerations are : 

1, to combat the general plethora by a certain amount of loss of blood ; 

2, to excite the skin by irritating frictions, by the use of flannel, and 
all means proper to establish the cutaneous circulation. The vapor 
baths, for the administration of which M. Peligot has arranged an inge- 
nious plan at the ' Hospice des Enfans Trouve's,' have not produced, 
according to M. Baron, as good effects as frictions and the application 
of flannel. I have often seen these latter means succeed perfectly. 
The respiration, during the bath, is sometimes painfully impeded, and 
occasionally congestions and sanguineous effusions into the lungs or 
brain have followed their administration." 1 

Andry, Auvity, Louvelle, Underwood and others, agree that the 
principal means of relief are warm baths and frictions with flannel. 

M. Valleix is a decided advocate for the abstraction of blood by 
leeches, but even in some cases where they had afforded relief, the child 
was carried off by erysipelas. 

In addition to the means for the relief of congestion, our endeavors 
must be to excite the lungs to action and to restore warmth to the 
child. It might be worth while, I think, to try the effect of electro- 
galvanism through the lungs, and internally we may administer ammo- 
nia in almond milk or wine whey if the child can swallow. 

Some attention should be paid to the bowels, either by purgative 
enemata, or, as Underwood advises, by placing a grain of calomel ia 
the mouth. 

1 Mai. des Nouveaux-nes, p. 208. 



SECTION VII. 



FEVER) 



CHAPTER I. 

INFANTILE REMITTENT FEVER. 

1. No doubt many of the diseases of infancy and childhood are ac- 
companied by fever, and to so great an amount as even to mask the 
local and primary disorder ; but besides these attacks, we find them 
liable to fevers, which, to a great degree, resemble those of the adult. 
Armstrong, Underwood, Hamilton, Butter, and more recent English 
writers have given us more or less full and accurate accounts of a fever 
which some call worm-fever, others mesenteric, gastric, or infantile 
remittent fever, and the more modern French writers have added a 
description of typhoid fever. That these are the same in kind, but 
different in degree, would, I think, be a hazardous assertion, notwith- 
standing these pathological resemblances, for the course and symptoms 
differ very considerably ; the former being very common in private 
practice, the latter rather rare. Amongst the poor, and in foundling 
or children's hospitals, both forms are sufficiently common. 

Infantile remittent fever is a disease to which children are very 
liable from one year old to ten or twelve, or even later. It is charac- 
terized by one or more daily exacerbations and remissions, by disorder 
of the stomach and bowels, occasionally by headache and by its uncer- 
tain duration. 

The best description of the disease will be found in Dr. Butter's 
essay ;* he divides the disease into three varieties — the acute, the slow, 
and the low remittent ; the lattey. appears to me to resemble typhoid 
fever. Others speak of acute and chronic remittent. The variations 
seem to depend chiefly upon the progress and duration of the disease, 
its complications, the modifications impressed upon it by the peculiar 
constitution of the child, or the prevailing epidemic influence. 

2. Symptoms. — In some cases the disease commences quite suddenly 
by a severe febrile paroxysm in the night, with heat of skin, quick 
pulse, flushed face, &c. The thirst is intense, the tongue dry and 
furred ; there is restlessness and agitation, perhaps delirium ; the 
child, if old enough, complains of headache, intolerance of light and 

' A Treatise on the Infantile Remittent Fever, 1782. 



INFANTILE REMITTENT FEVER. 685 

sound, and soreness or pain in the belly. Nausea and vomiting not 
unfrequently occur, and the matter vomited is yellowish or greenish, 
and has a sour smell. Towards morning, these symptoms abate, the 
skin becomes cooler, the pulse quieter, and the tongue more moist, but 
still the skin remains dry, the tongue loaded, and the pulse quicker 
than natural. The child is uneasy and fretful, the abdomen mov^ or 
less tender, the urine scanty and high colored, and afterwards oftc i 
depositing a white sediment, or becoming white and chalky, although 
clear and of the ordinary color when passed. During the day there b 
a still further improvement, and the child may even regain some of its 
natural liveliness, although the occasional languor and uneasiness reveal 
the remains of indisposition. Towards evening the paroxysm returns, 
with fever, uneasiness, headache, &c, as before, to be succeeded by a 
remission in the morning. 

3. Or, as in many other cases, the attack may come on more gradu- 
ally, preceded several days by indisposition. The child looks unwell, 
is uneasy and fretful, picks its nose, has heavy, offensive breath, with 
a short, dry cough, loss of appetite, pain in the head and abdomen, and 
occasionally flatulent enlargment of the latter. The sleep is uncom- 
fortable, and interrupted by starting, moaning, and grinding the teeth. 
The urine is scanty, turns milky soon after it is passed, or deposits a 
whitish sediment. The bowels are irregular, often in extremes, either 
costive or too free. 

Soon after this the fever is developed, ushered in sometimes by a 
cold fit with rigors ; sometimes stealing in so quietly that its commence- 
ment is not noticed. The paroxysm comes on in the evening, as I have 
just described, with hot skin, quick pulse, great thirst, flushed face, &c, 
lasting during the night, and followed by more or less complete remis- 
sion in the morning and during the day. When the fever is very 
severe, the remissions are shortened and less perfect, or may even be 
scarcely perceptible. 

During the exacerbations, all the symptoms are aggravated ; the child 
is drowsy, but sleeps uneasily ; it moans, starts, and talks incoherently, 
or it may wake with a scream ; the skin is hot, the pulse rapid, varying 
from 140 to 160, the respiration quick and hurried ; there is a dry cough, 
uneasiness in the bowels, with flatulence, and occasionally nausea and 
vomiting. 

During the remissions, all the symptoms subside to a certain point, 
the patient is tolerably lively and cheerful, the skin cooler, the pulse 
from 100 to 120, and if he sleep, he does so quietly and calmly. 

In the majority of cases the paroxysms occur but once in the twenty- 
four hours, and in the evening, but they may be more frequent. There 
are sometimes three in the same space of time, one in the morning, 
another at noon, and a third, the longest and most severe, in the night, 
but such cases are very rare. Ordinarily, the daily paroxysm, with 
remission, is the characteristic of the disorder, and continues during 
its entire duration, but some changes take place in the other symptoms, 
and the impression made upon the child by the pain varies in its in- 
tensity. For example, the headache, which is generally troublesome 



686 INFANTILE REMITTENT FEVER. 

at the beginning, especially during the exacerbations, gradually ceases, 
unless there occur some cerebral complications. 

The cough continues longer, but if there be no pulmonary disease, 
it is only occasional, not very troublesome, and by degrees diminishes. 
The respiration is always hurried during a paroxysm, and is hardly as 
quiet as usual during the remission, but nothing is heard beyond a 
mucous rale, and percussion gives a clear sound. The breath has a 
sickly odor, and is sometimes very offensive. 

The local irritation, which is frequently developed the first, or if 
not, which is certainly the most common, and persists the most obsti- 
nately, is disorder of the intestinal canal. The appetite entirely disap- 
pears, but the child is extremely thirsty. 

Dr. Pemberton observes that, " digestion seems perfectly at a stand, 
for the food which is taken into the stomach will often be brought up 
unaltered, though it shall have remained down a considerable time. 
The intestines also seem in a manner paralyzed ; they exert no action 
on the food, for it passes off like a mass of putrid vegetable and animal 
matter, which has been sometimes subjected to heat and moisture, with- 
out its having the smallest resemblance, either in appearance or smell, 
to those faeces where the powers of digestion have been exerted. When 
the disease has continued for some time, the appetite is so totally 
destroyed that for six or eight days together, I have known the whole 
nourishment to consist of about half a pint of toast and water in the 
twenty-four hours." 1 

The state of the bowels is very irregular and uncertain ; they are 
sometimes constipated at the beginning and then attacked by diarrhoea; 
or they may be too free from the commencement, and afterwards the 
diarrhoea may continue or alternate with constipation. I think that in 
the majority of cases the bowels are too much moved, and with con- 
siderable irritation. The amount of each discharge varies a good deal : 
sometimes there are copious evacuations ; in other cases, very little 
faecal matter, with much wind. The character of the stools is un- 
healthy, and highly offensive; they may be clay-colored, or dark and 
slimy, resembling tar, or occasionally mixed with mucus, and even 
blood. In the latter cases the attack assumes very much the character 
of dysentery. 

The abdomen feels very hot to the hand, is somewhat tender on 
pressure, and the child now and then complains of pain in the bowels. 
In some cases the belly is distended with flatus, but more frequently it 
i{5 flat, or even concave. Worms are sometimes discharged by stool, 
:;.nd this has given rise to the opinion that the disease is caused by 
them ; occasionally, but very rarely, they are ejected from the stomach, 
and now and then they have been observed to crawl out of the anus 
spontaneously. 

The urine, which at first turns white soon after it is discharged, in 
general becomes yellow and highly transparent. 

Dr. Condie mentions that he has noticed a rose- colored lenticular 
eruption upon the abdomen and inner surface of the thighs, and occa- 

1 On various Diseases of the Abdominal Viscera, p. 165. 



INFANTILE REMITTENT FEVER. 687 

sionally sudamina upon the abdomen or along the front and sides of the 
neck. Dr. Coley states that he has observed a scaly desquamation of 
the cuticle in remittent fever, resembling that in scarlatina, and also 
that described by Dr. Pemberton as peculiar to disease of the mesen- 
teric glands. 1 

4. The disease may go on thus from day to day for an indefinite 
time -without any very formidable symptoms arising, but without any 
advance being made towards cure, the child becoming weaker and 
thinner until it is so reduced in flesh and strength that recovery seems 
most improbable, and yet even from this state they rally astonishingly 
if no complication take place. By slow degrees the bowels become 
more quiet and regular, the discharges more healthy ; the urine again 
deposits a copious sediment ; then the tongue becomes cleaner and the 
pulse falls, a gentle moisture appears on the skin, the sleep becomes 
quiet and refreshing, and the daily exacerbation ceases to occur. The 
pulse, however, in some cases, remains quicker than natural for a time 
after the other symptoms have disappeared. 

On the other hand, the result in many cases is not so favorable; the 
child may sink from exhaustion or from the intestinal aifection taking 
on a more serious character, presenting the form of entero-colitis or 
colitis, and in its reduced state, proving rapidly fatal to the child ; or 
lastly, and perhaps more commonly, the nervous system may become 
implicated and the child be carried off by a convulsion or by an attack 
of secondary meningitis. Of these complications I shall say a few 
words presently. 

The duration of this fever is both uncertain and variable ; it may 
last from a week to a month, and it very rarely indeed terminates by 
a crisis. 

5. But not only is the duration variable, but also, if I may use the 
expression, the rate of progression, and this is probably a sufficient ex- 
planation of Dr. Butter's slow variety, in which he remarks that the dis- 
ease comes on gradually and unnoticed ; the child slowly declines, the 
appetite diminishes, then fails altogether ; the breath is offensive and 
the abdomen enlarged. One daily exacerbation occurs in the evening 
and lasts until morning, succeeded by a profuse sweat. During the 
day, the skin is dry and harsh, and there is a hectic flush upon the 
cheeks. The pulse ranges from 100 during the remissions to 140 dur- 
ing the exacerbations. The child is sleepy, dozing uneasily, with 
starting and moaning, and, when awake, he picks his nose and fingers 
until they are sore. The tongue is white, loaded, and moist; there is 
no appetite, and but little thirst; the urine is of a deep yellow color, 
and in the morning contains a sediment. The stools are unhealthy, 
and of the same kind as in the former variety. 

This form of disease may be developed very slowly, and may last for 
one or two months, reducing the child as much, but less rapidly, as the 
other form. 

Dr. Condie has given a description of a chronic form of the disease, 
which answers pretty accurately to this slow variety of Dr. Batter: 

1 Diseases of Children, p. 190. 



688 INFANTILE REMITTENT FEVER. 

"The exacerbations," he says, "are of longer duration, but marked 
by symptoms of less intensity than in the more acute attacks of the 
disease ; the remissions are also less distinct. The abdomen is usually 
tender and hot, and generally tympanitic ; the bowels are often affected 
with diarrhoea, the dejections being always unhealthy in appearance, 
and fetid. The tongue is thickly coated on its upper surface with a 
yellowish or brownish mucus, and red and dry at its point and edges ; 
the teeth are often covered with sordes, and the lips parched and 
cracked ; the urine is scanty and high-colored, throwing down a 
copious white sediment, particularly during the remissions ; the skin 
is dry, harsh, and of a sallow or dirty hue ; the countenance is con- 
tracted and wrinkled, presenting the appearance of premature old age. 
The appetite is often unimpaired, and in some cases it is even vora- 
cious ; in general, however, it is altogether lost. The child is very 
generally affected with a short, hacking, frequent cough. Most com- 
monly there is urgent thirst. There is always more or less fretfulness 
and the usual indications of suffering, and the patient exhibits a dispo- 
sition to pick almost constantly at some portions of its face or body, or 
at the bedclothes, or at the face and arms of its attendants. If there 
be an accidental pimple on the skin, this will usually be picked until 
a sore be produced, the edges of which are still more eagerly attacked, 
so that the fingers are constantly stained with blood. This picking is 
by many considered to be one of the diagnostic symptoms of infantile 
remittent fever ; it is, however, a common phenomenon in all the 
chronic affections of childhood, and is often observed when no disease 
whatever is present." 1 

6. Yet again, the symptoms and course of the disease may be 
varied by the constitution of the individual, or perhaps by the atmo- 
spheric constitution of the time, to produce what has been termed the 
low form of infantile remittent ; and I gladly avail myself of the sum- 
mary which Dr. Joy has given us: "The low infantile fever begins 
suddenly, and for the first week perfectly resembles the acute, save 
that the head is more affected, and delirium sometimes occurs. After 
this the low state succeeds, the child becoming quiet, indifferent to 
surrounding objects, and indisposed to answer questions. He rarely 
asks for anything, but takes his food or drink when it is offered to 
him. The trunk and lower extremities generally remain fixed in one 
posture, but the arms and hands are almost always in motion when he 
is awake; sometimes he flings them about, and at other times picks not 
only his nose and lips, but even his tongue, eyes, and other parts of his 
face, till they become sore. At the height of the disease the difficulty 
of replying to questions, arising from debility, terminates in a temporary 
loss of speech and voice, and the jaws are occasionally locked together. 
He slumbers much during the exacerbations, and in the remissions per- 
forms with his hands the gesticulations above described. When the low 
stage sets in, the eyes are reddish, dull, and inattentive ; the counte- 
nance is expressive of distress; and the tongue, teeth, and lips, are 
covered with a blackish fur. The patient is particularly uneasy before 

1 Diseases of Children, p. 273. 



INFANTILE REMITTENT FEVER. 689 

stools, or the escape of flatulence; the urine and stools which are 
of unnatural appearance, are involuntary, yet he is quite sensible ; 
the pulse, which is about 100 in the remissions, rises to 120 in the ex- 
acerbations. When the disease takes a favorable turn, the exacer- 
bations become shorter, the child is less drowsy, the eyes are clearer 
and more observant, the countenance is placid, and the tongue cleaner, 
the pulse is calmer, and the appetite returns; the voice is regained, 
and, though weak, at first, soon becomes stronger, and is frequently 
exercised, as he cries whenever he is disturbed or wants anything, 
or if he feels himself unable to reply to questions, or to put out 
his tongue when desired. The strength, flesh and color are gradually 
recovered, and he yawns, sneezes, or coughs, which he was previously 
unable to do; the urine, which is of a straw color, is still for a consid- 
erable period passed involuntarily; the crying and fretfulness long con- 
tinue; the stools at length become natural, and there is no complaint 
made but of weakness. The pulse occasionally continues accelerated 
till the recovery is complete. The duration of this fever is from a 
month to six weeks, or even longer." 1 

In practice, various modifications, both of the symptoms and course 
of the disease, are observed, all of which cannot easily be enumerated. 
One of them has been noticed by Huxham, who says: "In the fevers of 
children the face is sometimes drawn to one shoulder. I have often 
seen this, but never knew it continue long after the fever was cured." 
Underwood has noticed this also; and Dr. Joy adds, a tenderness and 
"intolerance of pressure in the upper part of the spine; with this, a 
general increase of the sensibility of the whole surface of the body seems 
sometimes to co-exist, so that the child can scarcely bear to be touched 
in any part." 

7. Complications. — As I have already stated, the child may no 
doubt sink from exhaustion in this disease, but I am sure that all who 
have had much experience, will agree with me that the chief danger is 
from the complications which occur at different periods of the fever. 
The principal ones are the following : — 

I. Convulsions or Meningitis. — It is rarely we see convulsions at the 
commencement of the fever. I have, however, known the nervous 
system very much disturbed in one or two cases, as was marked by 
visions when awake, distressing dreams and startings when asleep. 
But in general it is only after some time when the disease has reduced 
the strength of the child, and at the same time increased the irritability 
of the nervous system, that the attack is to be feared. Sometimes the 
child is attacked by one or more convulsions, followed by stupor, occa- 
sional staring, twitching of the muscles, &c, or the symptoms of 
secondary meningitis may gradually steal on without a convulsion. 
We may find the child heavy, with diminished intelligence and sensa- 
tion, with the hands clinched, the thumbs turned inwards, the eyes 
staring and twinkling, and repeatedly sighing. Or the child may be 
restless, crying, rolling the head, picking the limbs, &c, and by and 
by there may follow an attack of convulsions, or paralysis of one side 

1 Cyclop, of Pract. Med., vol. ii. p. 241. 

44 



690 INFANTILE REMITTENT FEVER. 

of the body, and convulsive movements of the other. The symptoms 
of meningitis are generally modified by the weak condition of the child, 
and some may be absent, or the child may be carried off before time 
has been allowed for their development. 

This attack may be regarded as a reflex irritation from the disordered 
intestinal canal, ending, in many cases, in inflammation. It is a very 
fatal complication, and in remittent fever is always to be dreaded ; no 
visit should be made without a careful scrutiny into the condition of the 
nervous system, nor a moment lost when any suspicious symptom arises. 

II. PJntero-colitis, or Colitis. — That remittent fever is always accom- 
panied with more or less gastro-enteric irritation is quite evident, but 
there is room for doubt as to whether this amounts to inflammation in 
ordinary cases. In certain cases, however, this complication does take 
place, and it may occur at any period, either early, or, which is more 
common, at an advanced stage. 

Enteritis will be marked by an increase in the intensity of the ab- 
dominal symptoms, such as the pain, tenderness, tympanites, diarrhoea, 
&c. Colitis or dysentery, by the frequent desire to go to stool, and 
the substitution of small quantities of mucus and blood for the former 
unhealthy discharges, with tenesmus, and the other symptoms of dysen- 
tery, general and local, already described. 

in. Bronchitis or Pneumonia. — From the beginning there is gene- 
rally a troublesome cough, indicating that the mucous membrane of 
the bronchial tubes, as well as that of the intestines, is in a state of 
irritation, and this not unfrequently degenerates into an attack of 
bronchitis, with the usual symptoms and signs. It is more rare, though 
not very uncommon, to find an attack of pneumonia supervene. 

IV. Paralysis. — When an infant recovers from remittent fever, it is 
sometimes found to have lost, partially or wholly, the use of a limb or 
of certain muscles, as I have already noticed when treating of paralysis. 
These effects may be the consequences of inflammation of some portion 
of the nervous system, but more frequently they seem to be the results 
of reflex irritation. 

v. Pericarditis. — This cannot be a frequent complication, as it is 
not mentioned by any writer, I believe, but as a well-marked and ulti- 
mately fatal case occurred in my own practice, I think it right to men- 
tion it. 

8. Pathology. — In cases -which have proved fatal, we invariably 
find a certain amount of disease of the intestinal canal, but it may 
not be easy to separate the amount of disease due to the existing com- 
plications. Evidences of inflammation, varying in extent and intensity, 
are generally found in the stomach and small intestines, sometimes in 
the ilium chiefly, or in the ilium and colon. The mucous membrane 
is reddened in patches, or exhibits red striae or points, or it may be 
thickened, softened, or ulcerated. The isolated follicles are generally 
enlarged, as well as the patches of follicles in the small intestines, and 
they are sometimes softened or ulcerated. The mesenteric glands are 
frequently enlarged, sometimes considerably, and they have been found 
in a state of suppuration, and containing tubercular matter. The liver 
is sometimes congested, but rarely the seat of organic disease. 



INFANTILE REMITTENT FEVER. 691 

When the patient has been carried off by meningitis, colitis, or en- 
tero-colitis, or disease of the lungs, the usual appearances will be 
found. 

We now come to the consideration of the nature of this fever. Is 
it a fever depending upon the presence of worms, or is it a gastro- 
enterite, or a fever with gastro-enteric complication, but not caused 
thereby ? 

In favor of the first opinion we have the authority of some who were 
great authorities in their day (Baglivi, Hoffmann, Sauvages, &c), and 
the fact that worms are occasionally discharged, but neither of these 
is conclusive. In the majority of cases no worms at all are discharged, 
and they are rarely detected by a post-mortem examination. 

We must, therefore, seek for some more general pathological condi- 
tion to explain the disease, and as the symptoms during life generally 
indicate gastro-enteric disturbance, and the post-mortem appearances 
are those of irritation or inflammation of the gastro-intestinal mucous 
membrane, that has been generally assumed by modern writers to be 
the essential element of the disease. Thus, for example, Dr. Under- 
wood considers it merely as an affection of the primas vise. Dr. But- 
ter attributes it to a debilitated condition of the digestive organs, and 
to an accumulation of unhealthy secretion in the bowels, connected 
with the peculiarly sensitive constitution of children. Dr. Pemberton 
regards the fever as symptomatic of derangement in the intestinal 
canal. Dr. Eberle agrees with those who attribute it to irritation 
located in the stomach and bowels, with disorder of the biliary organs. 
Dr. Stewart, that "the great cause is excitement of the intestinal mucous 
membrane." Dr. Condie considers it in every case as " the result of 
inflammation, most commonly subacute, of the digestive mucous mem- 
brane." Sir Henry Marsh observes that "its characteristic symptoms, 
if closely analyzed, will all of them be found to point to the mucous 
surface as the original seat of morbid action," 1 with which opinion 
Maunsell and Evanson concur. Dr. Joy regards it merely as a variety 
of gastric fever, modified by the irritable constitution of infanc}\ 

The French authorities are nearly unanimous in regarding the disease 
as " gastro-enterite," and the fever as symptomatic. 

At the same time, however, I may observe that if there be a doubt 
whether the morbid condition of the intestinal mucous membrane be 
the cause, or only a concurrent symptom of the continued form of 
adults, the doubt is equally applicable to the remittent fever of chil- 
dren. I can quite easily believe that although certain pathological 
conditions may be found in both, yet in both these may not be the 
essential cause, but rather the effect of a continuance of the disease, 
the essence of which is more general. 

9. Causes. — Cold, teething, irregular or unwholesome food, or excess, 
with neglect of the bowels, seem to be the principal exciting causes of 
the disease. I am not sure whether over-dosing with purgatives may 
not also give rise to it. It has been said to be contagious, but I believe 
very erroneously. That it prevails epidemically, appears beyond doubt. 

1 Dublin Hosp. Reports, vol. iii. p. 316. 



692 INFANTILE REMITTENT EEVER. 

Dr. Butter speaks of it as either sporadic or epidemic, and Dr. Sims 
has described an epidemic which occurred at the same time with the 
prevalence of a low nervous fever among adults. "It was called," he 
says, " by some a worm-fever, though I believe worms were seldom the 
cause, yet, as that lay apparently in the stomach -and intestines, the 
error did not materially affect the practice." 

10. Remittent fever may also occur as a secondary affection in the 
course of or subsequent to other diseases, and when it does so it may 
exert a very unfavorable influence upon their character and terminations. 
Thus we find it complicating hooping-cough and other pulmonary affec- 
tions; following upon the sudden cure of an eruption ; as one of the 
sequelae of scarlatina or measles; or as a termination of dysentery. The 
characteristic symptom, i. e., an evening exacerbation, followed by a 
remission, is always present, although from the presence of concurrent 
symptoms of another kind, it may require more care than usual to satisfy 
one's mind. 

11. Diagnosis. — I. The most important point, and in many cases 
our greatest difficulty, is to distinguish remittent fever with certain 
symptoms, from some forms of meningitis, and not only is it far from 
easy, but in many cases, towards the end of the disease it may be im- 
possible, because of the supervention of certain head symptoms, such as 
drowsiness, staring, starting from sleep with screaming, &c, which may 
be either functional disturbance, the result of irritation merely, or the 
commencement of hydrocephalus. In such cases, time and the result of 
treatment are our only helps. 

In other cases it may assist us to remember, that in remittent there 
are no distinct stages, no changes in the pulse, such as we noticed in 
meningitis ; that there is a distinct remission which there is not in me- 
ningitis ; that the disease lasts for a much longer time ; that the heat of 
the head is not specially increased; that there is not generally clinching 
of the thumbs and toes, or twitchings ; that the head is not rolled or 
tossed about ; that, except at the first, there is no intolerance of light 
or sound; that the intellects are not obtuse ; and that, unless complicated, 
there is no convulsion. Further, although there may be occasionally 
vomiting, there is sufficient gastro-enteric irritation to account for it, 
and very much more than is usual in hydrocephalus. 

There is some degree of resemblance occasionally between remittent 
fever and mesenteric disease. Dr. Coley observes they may be dis- 
tinguished " by the accession of fever occurring in the latter, generally 
in the evening only; by the child being more restless at that time instead 
of being inclined to sleep ; by the intestinal evacuations having but lit- 
tle alteration from their natural appearance ; by a peculiar mark of dis- 
tress in the countenance ; by the sleep in mesenteric disease, after the 
paroxysm of pain has subsided, being for the most part undisturbed ; 
and by the length of time the complaint has existed. The fever accom- 
panying the disease in the mesenteric glands is of a hectic nature, and 
always periodical, gradually terminates with proper perspiration, and 
is free from delirium." 1 I should rather depend upon the latter cha- 

1 On Diseases of Children, p. 192. 



INFANTILE REMITTENT FEVER. 693 

racteristics than the former, adding to them the fact, that in an advanced 
stage of tabes mesenterica, the enlarged glands can generally be felt. 

11. Prognosis. — Notwithstanding the lengthened nature of the attack, 
and the great extent to which the child is reduced, if there occur no 
complication, the prognosis is by no means unfavorable. The majority 
of such cases recover; and those who die, either sink from exhaustion, 
or, more commonly, are carried off by some complication. Convulsions 
or hydrocephalus, coming on after the disease has lasted some time, are 
almost invariably fatal. Pulmonary or intestinal inflammation, though 
not so certainly mortal, are frequently so, and require not merely great 
care and skill, but a strong constitution on the part of the child, to en- 
able it to struggle through. 

The diminution of the exacerbation, the return of healthy evacuations, 
of sleep, appetite, and a quiet pulse, are all favorable symptoms; whilst, 
on the other hand, an increase of fever, with either abdominal, pulmo- 
nary, or, still worse, cerebral symptoms, is highly unfavorable. 

12. Treatment. — Very active antiphlogistic treatment is out of the 
question in uncomplicated cases of infantile remittent, but when the 
pain and tenderness of the abdomen are more than usual, a few 
leeches may be useful, followed by poultices, but it is rare that we 
find them necessary. In the majority c.f cases, one of the very first 
things to be regulated is the diet and regimen of the patient ; if he be 
not already in bed, he should be placed and kept there. The feverish 
restlessness and the natural impatience of children, often render this 
unpleasant to them, and nurses are induced to indulge them, but I am 
satisfied that much injury may be done by taking the child up Avhen it 
is restless. Let it be lightly covered, and placed in a well-ventilated, 
cool room, and let it understand that it must remain in bed, and its im- 
patience will generally cease. It will be well to examine the gums, and 
scarify them thoroughly if there be any evidence of irritation from the 
teeth. 

The next question concerns the state of the bowels : if we see the 
child early in the attack, and they be constipated, a brisk purgative will 
be very useful, either calomel with rhubarb or jalap, or calomel followed 
by castor oil, will generally act mildly and fully. Dr. Butter preferred 
the sulphate of potash or some of the neutral salts ; Sydenham gave an 
infusion of rhubarb in beer ; Dr. Hosack infusion of senna with super- 
tartrate of potash and manna. I do not think it matters much what 
medicines we use, provided the bowels are fully evacuated. On the 
other hand, and quite as frequently, the bowels may be too free, or 
purged frequently, but in small quantities indicating a considerable 
amount of irritation ; our object in these cases will be to quiet them by 
chalk mixture with a few drops of laudanum, or by a mixture of muci- 
lage, syrup, caraway seed water, and a small dose of laudanum. I have 
also found great benefit from Prussic acid in minute doses (J to J of a 
drop three or four times a day) in quieting this irritation, and it has 
the advantage of soothing the bronchial irritation at the same time. 

Dr. Butter gave hemlock when diarrhoea was present : he dissolved 
five grains of the extract of conium in four ounces of water, and gave 



694 INFANTILE REMITTENT FEVEK. 

two teaspoonfuls for a dose to child of five years old. He thought it 
both checked the looseness and relieved the fever. 

Having by these or similar means regulated the bowels, we may next 
proceed to combat the disease by giving small doses of calomel and an- 
timonial powder, as Dr. Cheyne advises. He says, "antimonials in 
combination with cathartics, and more especially calomel, have appeared 
to me very useful in those cases of infantile remittent fever in which the 
sensorial functions are much oppressed, as also in the commencement of 
febrile attacks of a less definite nature, which are liable to degenerate 
into hydrocephalus. In such cases I prescribe a pill of calomel and 
antimonial powder, three times a day, interposing between every two 
pills a moderate dose of the common purgative mixture." 

When the bowels are too irritable to bear calomel, the hyd. c. creta 
and Dover's powder, and sometimes ipecacuanha, may be substituted 
Avith great benefit. Two grains of the former, with half a grain of each 
of the latter, may be given three times a day to a child of three or four 
years old. 

A saline diaphoretic or diuretic mixture may also be advantageously 
exhibited, provided the bowels are not too irritable to bear it. 

Warm baths, fomentations, or still better, poultices to the abdomen, 
afford great relief; the latter I often directed to be made of linseed 
meal, with a small portion of flour of mustard. Or we may use rubefa- 
cient or slightly irritating liniments, containing laudanum, if there be 
much pain or irritability of the bowels. 

Dr. Merriman observes: "Some practitioners seem to rely upon purga- 
tives alone, but the saline mixture, nitre, and antimonials, assist so much 
in abating the disease, that they ought not to be omitted; and in cases 
of great irritability, small doses of the milder narcotics are to be em- 
ployed ; nor ought the advantages to be overlooked which may be 
gained by pediluvia, fomentations to the abdomen, and ablutions with 
tepid water. As the disease advances, bitters, ammonia, bark, the 
mineral acids, &c, may be required." 

If the cough be troublesome, some soothing, expectorant mixture may 
be ordered. Ipecacuanha, or squills in almond milk, with a little para- 
goric, answers the purpose very well, or almond milk with laurel water, 
or the small doses of hydrocyanic acid I have already mentioned. 

13. When the disease has lasted for some time (but the precise mo- 
ment must be left to the judgment of the practioner), we may have re- 
course to mild tonics. 

Dr. Pemberton, indeed, gave a light infusion of cascarilla, three times 
a day throughout the whole disorder. 

Minute doses of quinine may also be given, and Dr. Clarke is an ad- 
vocate for their early employment. After giving an emetic and a pur- 
gative he at once began with the bark. " By this means," he says, 
"the nervous symptoms which so frequently accompany fevers in the 
delicate habits of children, are, for the most part, happily obviated." 

Dr. West speaks favorably of the following prescription, if there be 
no abdominal irritation, viz : four minims of dilute hydrochloric acid, 
eight of the compound spirit of sulphuric ether, and three drachms of 
camphor mixture, every six hours, for a child of five years old. 



TYPHOID FEVER. 695 

The diet should be very moderate, or even low, at first. Milk in every 
form, arrowroot, sago, gruel, tea, &c, may be permitted, with plenty 
of cold water if the child be thirsty. 

When, from the duration of the disease, weakness and exhaustion 
have resulted, we must improve the diet, and allow chicken-broth, beef- 
tea, &c. 

In some cases it is absolutely necessary to give wine and water or 
wine whey; nor have I found the tendency to cerebral complications at 
all increased thereby, if it be given in small quantities, frequently re- 
peated. 

During convalescence also, great care must be used, in returning to 
the usual diet, not to overfeed the child ; and in resuming its usual 
habits, that it shall not be exposed to cold. 

Of the treatment of the complications I need say very little, having 
entered fully into the subject under the different heads, but I may just 
observe that the activity of the treatment will be modified by the period 
of the disease and the condition of the child. If the head be affected, 
and the child able to bear them, a number (in full proportion to the 
strength) of leeches should be applied, but if the child be too weak, we 
must rely mainly upon counter-irritations and mercurials. The same 
remark applies to pneumonia complicating the disease, but in no case 
is an immediate impression upon the disease so urgently called for as in 
convulsions or threatened meningitis. 



CHAPTER II. 

TYPHOID FEVER. 



1. Without entering into the relation of typhoid fever to remittent, 
whether they are essentially different diseases, or different degrees of 
the same affection, for which this hardly appears a suitable place, I may 
remark that those who have seen them in private practice, and more 
especially as they occur in foundling or children hospitals, will have no 
difficulty in recognizing such a difference as will justify my giving a 
separate description. 

Although we occasionally meet with typhoid fever in private practice, 
in this country, I do not think it is very frequent, most cases of fever 
being rather the infantile remittent, but amongst the children of the 
very poor, badly fed, and of deteriorated constitutions, and especially 
when congregated together, it is sufficiently frequent both here and on 
the continent. It is rarely mentioned by British or American writers 
on diseases of children. 

On the continent I find that in 1834 Dr. Bell's Thesis was pub- 
lished, showing that the disease was not rare in infancy, and this was 



696 TYPHOID FEVER. 

followed by the reasearches of MM. Constant, 1 Larroque, Gendren, 
Littre', Becquerel, Taupin, 2 Killiet and Barthez, Audiganne, 3 Bricheteau, 
and Barrier, &c. 

It appears that typhoid fever is not so common among infants as re- 
mittent; it rarely occurs during the first years of life, nor is it frequent 
until 8 or 9, and upwards. M. Charcelay, however, has published 
some cases in new-born infants. 4 

2. Symptoms. — The attack generally commences without anything 
distinctive, resembling the febrile attacks of children in general. The 
child complains of lassitude and weakness, indisposition to exertion, 
either mental or physical, occasionally with rigors followed by heat; 
either he is sleepless, or his sleep is restless and disturbed; there is 
generally headache or a sense of heaviness in the head, with aching of 
the loins and limbs, thirst, loss of appetite, and derangement of the 
digestive functions, &c. 

These symptoms may continue for a few days or a week, the fever 
becoming gradually more developed, with great thirst, sore throat, some- 
times vomiting, uneasiness or pain in the bowels, diarrhoea, loaded 
tongue, &c. The fever is generally continuous, but occasionally with 
remissions. 

The headache is still troublesome, and the child complains of giddi- 
ness in attempting to sit up or walk; the sleep is much disturbed, and 
sometimes the patient is harassed by visions and hallucinations ; the 
countenance loses its natural expression and becomes heavy. The 
intelligence is diminished, and answers to questions are made slowly 
and apparently with difficulty. Epistaxis frequently occurs. 

As the fever increases, all these symptoms are aggravated, diar- 
rhoea occurs, the abdomen becomes tympanitic, the pulse is full and 
frequent, the skin burning and dry, very rarely moistened by per- 
spiration. In some cases the patient is delirious, and cough and rales 
announce the presence of bronchial catarrh ; the urine is scanty and 
of a deep color. Sometimes during this stage, the rose-colored lenti- 
cular eruption makes its appearance, although it is generally some- 
what later. This stage has been regarded as analogous to the period 
of invasion of eruptive fevers, and it generally continues about a week. 
The next period, analogous to the stage of eruption, is marked by an 
aggravation of the nervous symptoms, and of those referable to the 
bowels. For the most part, the headache disappears, or is less trouble- 
some, but there is greater prostration, the expression of the face is less 
intelligent; stupor and delirium alternate, the first chiefly by clay, and 
the latter by night; the senses are impaired and obtuse, especially the 
hearing; articulation is difficult, and the muscular strength is abolished, 
the patient lying almost constantly on his back. There are subsultus 
tendinum, convulsive movements, &c, and the bladder is more or less 
paralyzed. At the same time the diarrhoea continues, the evacuations, 
which are more or less ample, are often involuntary and unconscious. 
The tongue, mouth, and lips are dry, and loaded with sordes ; the patient 

1 Gazette Med., 1833-4-5-6. 2 Journ. des Connnis. Med., Not. 1839. 

3 Gaz. Medicale. 4 Journal de Tours. 



TYPHOID FEVER. 697 

swallows eagerly, but with some difficulty ; the abdomen is hot and tym- 
panitic, with rumbling and gurgling, especially in the csecal region. The 
cough, and dyspnoea are occasionally considerable, even when the stetho- 
scope indicates merely catarrh of the bronchial tubes. The pulse con- 
tinues quick, although smaller and weaker, and the surface is always 
hot and dry. 

From the commencement of this period we perceive the rose-colored 
eruption, and as it advances, sudamina, and sometimes petechia, and 
blue patches on the skin. Bed-sores also occur on the sacrum or other 
part upon which there has been much or continuous pressure. 

The third period varies in its characteristics, according as the fever 
is to terminate favorably or unfavorably. In the latter case, the stupor 
degenerates into coma, the subsultus and starting become constant, the 
intellectual functions are obliterated, the senses nearly extinguished, 
the pulse extremely rapid, but small, feeble and thready. The skin is 
cooler, and either dry or covered with viscid cold sweat; there is often 
complete incontinence both of urine and fasces, the emaciation is extreme, 
the face becomes hippocratic, the bed-sores increase, and lastly, the res- 
piration is embarrassed and becomes stertorous, and the patient expires. 

On the other hand, when the course of the disease is more favorable, 
we observe a gradual mitigation of the symptoms, except in the few 
cases where a crisis occurs. The stupor is dissipated, the face assumes 
an intelligent expression, the eye consciousness, and the hearing im- 
proves. Then the patient recovers the power of speech, he speaks 
slowly, but intelligently, the mental powers are exercised feebly, but 
healthily. By slow degrees, muscular strength returns, the weakness 
now being that of exhaustion and not of nervous oppression. The fever 
subsides, the skin becomes moist and fresh, the respiration is natural, 
and the cough disappears. The abdominal heat and meteorism dis- 
appear as the foecal evacuations become voluntary, less abundant, less 
fetid, and more natural; and the return of the appetite is an evidence 
that the patient is convalescent. But during recovery, much annoy- 
ance may be caused by indigestion or diarrhoea which follow any impru- 
dence or excess in diet, and which are generally remedied by care 
and restraint, although such a relapse may prove obstinate or even fatal. 

3. Modifications and Complications. — Although the preceding de- 
scription may answer for the generality of cases, we must expect, of 
course, many modifications. I. The attack may be very slight, and 
then many of the symptoms I have laid down will be absent, others will 
be much slighter, and the entire course much shorter. Or some par- 
ticular symptoms may offer an unusual degree of intensity or obstinacy. 

II. Vomiting is one of these exceptional symptoms ; it is much more 
common in the typhoid fever of children than of adults. Thus M. Tau- 
pin observed it in a third of his cases, MM. Audiganne and Barrier 
in about the same, and MM. Rilliet and Barthez in one-half of their 
patients. The vomiting may come on on the first, but oftener on the se- 
cond or third day, and, according to Rilliet and Barthez, are particu- 
larly common in those cases in which we have constipation instead of 
diarrhoea. They indicate that the case is a severe one. 

III. Diarrhoea, which is perhaps the least variable of the symptoms, 



698 TYPHOID FEVER. 

is nevertheless not constant. In about one-fourth of the cases there is 
constipation; neither when it is present, does it persist so steadily as in 
the adult, but it is interrupted and returns several times before ceasing 
or becoming permanent. The fecal discharges are generally fetid, yel- 
low, green, or brown, but rarely bloody. On the fifth or sixth day they 
escape involuntarily. 

The tympanitis, abdominal pains, gargouillement, and the tumefaction 
of the spleen are ordinarily very marked, and rarely absent in children. 

IV. The bronchial catarrh is as common in children as in the adult, 
at least it is rarely absent except in very slight cases. M. Taupin found 
it absent in four cases only out of 121, and M. Barrier in three out of 
twenty-four. 

v. The nervous symptoms are as frequent as in the adult, and of the 
same character, but of slighter intensity, which is remarkable, consider- 
ing the extreme susceptibility of the nervous system in children. 1 

VI. Epistaxis, which occurs occasionally, is much more rare with chil- 
dren than with adults. M. Taupin observed it six times in 121 cases. 
MM. Audiganne, Barrier, Rilliet and Barthez, in about one-fifth of their 
cases. 

vii. The rose-colored eruption and sudamina are almost always pre- 
sent, but the former are, however, frequently limited to the back. Other 
eruptions, erythematous, vascular, or hemorrhagic, are rather more fre- 
quent in children than in adults. 

4. Complications do not seem as frequent in children. I. Intestinal 
hemorrhage is extremely rare. M. Barrier mentions but one case in 
200. 

II. Inflammation and softening of the gastro-intestinal mucous mem- 
brane are by no means unfrequent; they occurred in four-fifths of Rilliet 
and Barthez's cases. 2 

More intense inflammation, followed by perforation and peritonitis, 
occurs occasionally, but it is not easy to say whether perforation is more 
frequent than in the adult. M. Taupin met with two examples in twen- 
ty-one deaths, and M. Barrier two out of three deaths. 3 The complica- 
tion is marked by violent pain, tenderness, vomitings, meteorism, &c, 
and when perforation occurs by collapse and death. 

III. Pneumonia is by no means rare ; it affects chiefly the more de- 
pendent portions of the lungs, and rarely is found beyond the first stage, 
and never beyond the second. MM. Rilliet and Barthez met with 
twenty-two cases of this complication. 

I need not say that any of these complications will add materially to 
the danger, and that some of them almost or altogether preclude the 
possibility of recovery. In all cases of fever it is of extreme importance 
that a vigilant watch should be kept for the early detection of any com- 
plication. 

5. Morbid Anatomy. — There is almost an identity between the mor- 
bid changes accompanying typhoid fever in children and adults. In 
both we find certain changes which are almost invariable, as those in the 

1 Stoeber, Clin, des Mai. des Enfans, de la Faculte, de Strasburg, 1841, p. 9 

2 Mai. des Enfans, vol. ii. p. 392. 3 Mai. de l'Enfance, vol. ii. p. 268. 



TYPHOID FEVER. 699 

intestinal follicles and the mesenteric glands, and others which are often 
wanting by their affecting the spleen, the bronchial tubes, the bladder, 

&C. 1 

The follicles may be found, at different periods of the disease, in a 
state of eruption, ulceration, or cicatrization. The changes affect equally 
the glands of Brunner and of Peyer, and may be observed in different 
part of the large and small intestines, but especially near the caecum. 

During the stage of eruption the agminated follicles assume two ap- 
pearances which are frequently united in the same subject, one of which 
has been termed the soft or reticulated patches, and the other the hard 
or figured. The former present the appearance of a membranous net- 
work, composed of a great number of small scales with depressions be- 
tween them. The muscular tissue which is involved is always softened, 
and sometimes to such a degree that it will not bear the least traction. 
Thus the softer or reticulated patches are characterized by extreme de- 
velopment and softening. The hard patches are very different; they 
are prominent, with their borders raised above the level of the mucous 
membrane, and unresisting to the touch. If we make a perpendicular 
section of one, we find first, the mucous membrane, which appears 
healthy, beneath that a moderately thick layer of a whitish, or yellowish 
substance, homogeneous, firm, and shining when cut. Beneath this we 
find the cellular membrane, muscular and serous tissues as usual. This 
submucous deposition characterizes these hard patches. Similar changes 
are found in the isolated follicles. The color of the mucous membrane 
is variable, sometimes it is pale, at others of a vivid red, or of inter- 
mediate shades. 

In the second period, the ulceration, which is a frequent but not neces- 
sary termination of congestion of the glands of Peyer, takes place in the 
following ways, according to M. Barrier. "1. It commences in the mucous 
membrane which covers the follicles, and spreads in depth and breadth. 
Occasionally several ulcerations are formed simultaneously on the surface 
of one reticulated patch, and uniting, form one large ulcer. 2. The sub- 
mucous deposit in the hard patches may be softened, or attacked by gan- 
grene, when it is eliminated by suppuration, and thus removes all or the 
greater portion of the mucous membrane. The remains of these figured 
patches, when colored by the bile, have received the name of yellow 
eschars. The new matter deposited in the isolated follicles often resembles 
a core, which comes away, leaving a solution of continuity. The ulcera- 
tions are generally oval in the patches, and round at the isolated follicles; 
their extent as well as their depth varies, the bottom being formed by 
the submucous cellular tissue, or by the muscular, or by the serous. 
Lastly, in more rare cases, there is perforation of all the tissues, and if 
adhesions have not been previously formed, the contents of the intestine 
escape into the peritoneum. The borders of the ulcer are sometimes 
thin and clear cut, or thick, rounded, and granular, sometimes adherent, 
sometimes separated ; the bottom is either smooth and uniform, or 
granular and unequal." 2 

1 Rilliet and Bnrthez, Mai. des Enfans, vol. ii. p. Sol. 

2 Mai. de l'Enfance, vol. ii. p. 245. 



700 TYPHOID FEVER. 

MM. Taupin, 1 Rilliet and Barthez have remarked that the period 
of ulceration is later in children than adults, although there are excep- 
tions, and also that cicatrization is more prompt and rapid. 

The stage of cicatrization is said to commence from about the fifteenth 
to the twentieth day, and is marked by the approximation of the borders 
of the ulcer, which become flatter and thiner, and by the filling up of 
its cavity by granulations. When the process is concluded, the mark of 
continuity in the mucous membrane is scarcely perceptible; it is smoother, 
without villi, and somewhat depressed at their points; at first of a deep 
red color, it afterwards becomes paler, and then resumes its natural ap- 
pearance. 

MM. Rilliet and Barthez state that the blood is most frequently 
fluid, or in dark, soft coagula, and that the vessels are often stained of 
a vinous red color. 

Such are the morbid changes found in the intestines in typhoid fever, 
but all may not always exist ; in some only the congestive stage, in 
others only the reticulated patches are found, and it is quite possible 
that the fever may exist without any of these changes being discover- 
able. 

Corresponding pretty accurately with the stages of the follicular de- 
velopment, we find congestion, inflammation, and purulent infiltration 
of the mesenteric glands. It is not found, however, that they open for 
the escape of matter into the peritoneum, but it is supposed that the 
matter is absorbed. This purulent infiltration of the mesenteric glands 
is as characteristic of typhoid fever as the follicular changes. 

Another organic lesion, which though by no means constant, is yet 
very frequent, is the tumefaction and softening of the spleen ; both are 
generally coincident, but in some rare cases there is softening with di- 
minution of volume. M. Taupin has observed apoplectic coagula,' and 
in one case the entire spleen resembles a large clot. 

Of course when complications have existed, the usual post-mortem 
evidences will be found, but they, as we have seen, are neither numerous 
nor frequent. 

There can be no doubt that the most important pathological change 
is in the blood itself, but unfortunately our means of investigation are 
limited, and the results as yet by no means satisfactory. 

6. Causes. — I have already mentioned that typhoid fever can hardly 
be regarded as a disease of infancy, being by no means frequent until 
about the 8th or 9th year. 

A very curious fact connected with the disease is its greater preva- 
lence among boys than girls. M. Taupin states that in 121 cases, 86 were 
males and 35 females, and Rilliet and Barthez that out of 111 cases, 80 
were males and 31 females. 2 It is very difficult to explain this, except 
by supposing a greater predisposition in the male sex. 

Typhoid fever does not appear to occur at all as a secondary affec- 
tion in the course of or subsequent to other diseases. 

Among the predisposing causes may be placed bad food, vitiated air, 

1 Jom-n. cles Connais. Med. Chir., Nov. 1839. 

2 Mai. des Enfans, vol. ii. p. 4Q-1. 



TYPHOID FEVER. 701 

and insufficient clothing, which by impairing the constitution prepares 
the child for serious illness. 

But the spread of the disease is most frequently due to epidemic in- 
fluence, -which, whether it originate or not in peculiarities of climate, or 
of seasons, or the hygienic condition of certain localities, hut which cer- 
tainly is propagated, and so to speak intensified by these circumstances. 
A very curious fact is recorded by M. Rilliet, who observed in 1840, in 
a village near Geneva, an epidemic of typhoid fever which was confined 
to the children, and which terminated favorably in all cases. At the 
same time there prevailed in a neighboring village, among adults, a most 
fatal ataxo-adynamic typhoid fever. 

Opposite opinions have been held as to the contagion of typhoid 
fever in children as well as in adults. The experience of French physi- 
cians is against it. Of M. Taupin's 121 cases, 5 only could have ac- 
quired it in this way; of MM. Rilliet and Barthez's 111 cases, 4 only 
were attacked in hospital, and they were in wards in which there was 
no case of typhoid fever, and of the 17 cases observed by M. Audiganne 
not one afforded the least presumption of contagion. 

7. Diagnosis. — There are several diseases with which typhoid fever 
has been confounded, and from which it requires great care to distin- 
guish it. 

I. Enteritis. — In some cases the history, symptoms, and course of 
the disease so closely resemble typhoid fever, that MM. Rilliet and 
Barthez have come to the conclusion that it is impossible to distinguish 
them; a conclusion very different from that of M. Louis, as regards 
these diseases in the adult. 1 In cases of secondary enteritis, the previ- 
ous affection will decide the question. 

II. Meningitis. — At the commencement these diseases resemble each 
other a good deal, but in typhoid fever the predominance of abdominal 
symptoms, and in meningitis, of head symptoms, soon becomes manifest. 
In meningitis we have convulsions frequently; never in typhoid fever. 
The pulse is occasionally irregular, the intellect less obscured for some 
time, and constipation more common; in typhoid fever there is delirium, 
mental obscurity, bronchial catarrh, frequent vomiting, diarrhoea with 
tympanitic belly, and tenderness, and further, the course of the two dis- 
eases is very unlike. 

III. Typhoid pneumonia has an aspect of typhoid fever, but a careful 
' investigation into the history of the case, and an examination by the 

stethoscope, will show the presence of primary pneumonia, and we shall 
at once detect the absence of the characteristic abdominal symptoms of 
typhoid fever. 

IV. Slighter cases of typhoid fever may easily be confounded with 
gastro-enteritis, or with any slight febrile attack, but though a little 
care will probably lead us to a correct conclusion, it is a comfort that a 
mistake here will be of no consequence. 

8. Prognosis. — When the fever is mild, and without complication, 
almost all the cases recover. Thus of 47 such cases observed by MM. 
Rilliet and Barthez, but one death occurred. The danger of perfora- 

1 Recherches sur la Fibvre Tjphcide, Pari?, 1844. 



702 TYPHOID FEVER. 

tion of the intestines so great in the adult, is comparatively slight in 
children, as this is a rare termination. 

Even in the more severe cases a considerable proportion recover, and 
the chief danger appears to arise from the complications. As M. Tau- 
pin observes, "the patients may die from the intensity of the pulmo- 
nary, abdominal or cerebral symptoms, from the abundant suppuration 
following the fall of the eschars, from intercurrent diseases in their weak 
state, from tubercular affections whose course is quickened by the fever, 
and from perforations of the intestine which may occur during conva- 
lescence in severe or even slight cases, so that we ought to be- very 
reserved in our prognosis. However, we ought never to despair, for in 
no other malady do more recover from such a hopeless condition so 
promptly." 1 

The intensity and persistence of the ordinary symptoms, their ataxic 
character, and the presence of any complication, may be regarded as 
unfavorable, whereas a moderate degree of diarrhoea and tympanitis, 
diminished vomiting, a clean tongue, a fairly developed pulse, &c, will 
afford us hope of a favorable termination. 

9. Treatment. — The principal indications are thus enumerated by 
M. Fabre : 1. To limit the intestinal inflammation and remove any 
irritating matters from the intestines, first by antiphlogistics, then by 
purgatives. 2. To prevent if possible the bronchial complication which 
so easily runs on into pneumonia by antiphlogistics, revulsives, and 
change of posture. 3. By similar means to control the cerebral affection. 
4. The general condition of the patient will require careful treatment, 
whether by soothing remedies, stimulants, or tonics. 5. The constitu- 
tion of the patient and the character of the epidemic will also furnish 
special indications. 

The treatment in fact of typhoid fever in children does not differ 
essentially from that required by adults, and therefore I need not enter 
very fully into details. 

Some modification of the antiphlogistic treatment is generally neces- 
sary, and in proportion to the intensity of the intestinal irritation. It 
is rarely necessary to open a vein, except when the fever is intense, 
but there are few cases which are not benefited by a few leeches to the 
abdomen or anus. 2 

After leeching, purgatives seem to be most beneficial; neither are 
they, according to M. Barrier, counterindicated by the presence of 
diarrhoea, although they are even more necessary when the bowels are 
constipated and tympanitic. Some prefer saline purgatives, others 
mercurials, and others, again, castor oil, or rhubarb. 

Emetics are sometimes very useful at the commencement of the attack, 
when the tongue is loaded, and the mouth bitter, &c, and ipecacuanha 
answers better than tartar emetic, because it causes less depression. 

During the second and third stage, counter-irritation produces very 
good effects, and it may be effected by dry cupping, rubefacient lini- 
ments to the abdomen, or by blisters which answer much better. M. 

1 Journ. des Connais. Med. Cliir., Nov. 1839. 

2 Barrier, Mai. de I'Enfauce, vol. ii. p. 284. 



TYPHOID FEVER. 703 

Barrier observes that " their action is double, at once revulsive and ex- 
citant : the first is useful when there is any indication of local conges- 
tion or inflammation, as of the chest or head, and above all, when 
antiphlogistics are insufficient or counterindicated. Their stimulant 
action, on the other hand, is valuable when there is much prostration. 
In other circumstances they may be injurious ; when there is much agi- 
tation, delirium, or other symptoms of excitement, we find that they 
rather aggravate this condition." 

Diaphoretic, diuretic, and soothing remedies are of use, and may be 
continued in moderate doses until the disease begins to decline. Se- 
datives also are beneficial in the first and second stages, especially when 
there is much disturbance of the nervous and circulating systems. A 
combination of gray powder 1 with James' and Dover's powder will some- 
times act remarkably well, or if there be restlessness, sleeplessness, and 
delirium, we may try a combination of tartar emetic and opium, in 
small doses, as recommended by Dr. Graves in the typhus of adults. 

Cold affusion has been strongly recommended by MM. Recamier and 
Gendrin, but I do not think it is commonly used. It should only be 
used when there is excitement, with heat of surface, and a pretty strong 
pulse, then it calms and quiets the patient, and leads to a more healthy 
action of the skin. 

At a certain period in the fever, but varying according to its charac- 
ter and the constitution of the patient, we shall find it necessary to give 
tonics and stimulants. When the pulse gives way, and the vital powers 
show signs of yielding, is our time to interfere, which may be done by 
some bitter infusion — bark, cascarilla, orange-peel, with ammonia or 
ether. These may be given freely, according to the condition of the 
patient and their effects. But in most cases we shall also find it advan- 
tageous to give wine, in water, whey, or arrowroot, and in such quan- 
tities as the case may demand. 

One of the nicest points in practice is to discover and to seize the 
time for the exhibition of tonics and stimulants, and one of the most 
gratifying to witness is the almost magical effect of the remedies thus 
applied at the right moment. 

Some writers have latterly recommended large doses of the sulphate 
of quinine in typhoid fever, but it is as yet extremely doubtful whether 
the results are likely to be as favorable as is expected. 

Of course, some variation and modification will be required if any of 
the complications I have mentioned should take place. They will rarely 
require much addition of antiphlogistic remedies, because the patient is 
rarely in a condition to bear this. Counterirritation by blisters to the 
head or chest, pushing the mercury a little further, as in cases of pneu- 
monia, the exhibition of small doses of tartar emetic, if the patient can 
bear it, are pretty nearly all the means at our command. 

Great attention should be paid to the hygienic condition of the patient. 
He should lie in a well-ventilated but warm room, lightly and comfort- 
ably clothed, with the observance of scrupulous cleanliness. His food 
and drinks must be of the mildest, lightest character. Water, milk, pa- 

1 [Hydrargyrum cum creta.] 



704 TYPHOID FEVER. 

nacla, arrowroot, &c, will be sufficient until an advanced stage of the 
disease, or the character of the symptoms demands a change. 

During convalescence, also, great care and watchfulness must be ob- 
served. The patient is very liable to relapses and to various complica- 
tions which are, of course, much more dangerous in the weakened 
condition of the patient. As soon as he has sufficient strength, he 
should be removed to the country, and allowed to be much in the open 
air, but guarded from cold. 






SECTION VIII. 

INFANTILE SYPHILIS. 



1. Very few of the diseases to which infants are liable, possess 
greater interest, and in some points none are of greater consequence 
than the syphilitic affections of infancy. "Whether we inquire into the 
circumstances under which the diseased parent or parents can infect 
their offspring, or the form in which the disease affects the infant, or 
the appearance and nature of those diseases which are communicated 
by the infant to the nurse, or of those communicated to its other at- 
tendants, and the further propagation of the disease by the nurse to 
her husband, and perhaps to a large family of children — I say, in in- 
vestigating any one of these points, we must be struck with the fact 
that we find, in each, a striking deviation from those laws which regulate 
the venereal disease, as communicated by the adult to the adult." 1 

But, moreover, in this question is frequently involved the peace of 
families, and upon the correctness of our diagnosis may depend the 
happiness of married life. If we hastily pronounce a child to be syphi- 
litic, we may sow distrust and suspicion between the parents, the fruit 
of which may be life-long misery, and on the other hand, a declaration 
that the affection is not syphilitic may lead to the direct communication 
of the disease to the mother or nurse, and indirectly to the rest of the 
family. Not merely, therefore, as a scientific matter, but really as a 
question of social morality, the subject is deserving of the most careful 
and thorough investigation. All our caution and all our observation 
will be little enough to enable us to estimate justly the history, symp- 
toms, course, &c, of these cases with anything like a certainty of ar- 
riving at a correct conclusion. 

2. Symptoms. — There has been a difference of opinion as to whether 
the foetus in utero could be the subject of syphilis, even though some 
authors admit that the disease in the mother may cause abortion or 
premature labor, and they either deny that the appearances observed 
upon the infant at birth were syphilitic, or they attribute them to the 
child having come in contact with a venereal ulcer of the vagina. M. Colles 
considers this latter supposition to have been effectually refuted by 
cases in which no such ulcers existed at the time of parturition, and by 
the fact of the symptoms in the infant being present at the moment of 
birth. 

The evidence of facts, however, appears to me too strong to admit of 

1 Colles, Pract. Obs. on the Venereal Disease, p. 262. 

45 



706 INFANTILE SYPHILIS. 

our holding this opinion; not only have we well marked cases on record, 
but even in the more obscure cases, traces may often be detected, and 
the success of treatment will often clear up the difficulty altogether. 

3. I. I shall first notice the disease occurring in utero and showing 
itself in infants at birth. 

I have already mentioned that syphilis in the mother is admitted as 
a cause of abortion or premature labor, but we are, I believe, indebted 
to the late Dr. Bently, of Dublin, for a knowledge of the fact that in 
many cases, when no venereal taint was suspected in either parent, but 
when the mother has repeatedly borne dead and putrid children, the 
true cause was a syphilitic taint, and the cure, the administration of 
mercury. 

M. Colles has described these cases with his usual fidelity. " The father 
of the child has had primary symptoms, six or eight months before his 
marriage; for these he had been treated by mercury ; has undergone a 
full course of this medicine, under which his symptoms have been re- 
moved, and his surgeon has declared himself satisfied with the treat- 
ment, and dismissed him as perfectly cured. In six or eight months 
after this treatment he marries. In the ordinary time his wife becomes 
pregnant, and carries the child until the seventh or eighth month, when 
abortion takes place, and this without being preceded by any of those 
circumstances which ordinarily contribute to its occurrence. The same 
fatality attends on the second, and third, and perhaps on the fourth 
pregnancy, in spite of every attention paid to the directions of her 
accoucheur. At length the suspicion arises in the mind of the ac- 
coucheur : he examines the product of the next abortion, and finds that 
the cuticle is loose, and that it readily peels off" in patches of greater or 
less extent: thus is explained what the midwife had termed a putrid state 
of the child ; he may find too that the nails are not formed, and in 
general that the child appears as if it had been badly nourished. It 
should be here remarked that sometimes the child is born alive, in such 
a weakly but emaciated state that it does not survive more than a few 
hours, and such often bear unequivocal marks of the venereal disease. 
Until these repeated abortions have attracted the attention of the ac- 
coucheur, there has not been any one circumstance which could have 
raised his suspicion as to the true cause of them ; for both parents con- 
tinue, all this time, to live in the enjoyment of perfect health — no trace 
of disease is to be discovered in either. When the husband is questioned, 
he candidly avows that he had, before marriage, been affected with pri- 
mary symptoms ; that he had been (as he thought) cured of them, and 
that having allowed six or eight months to elapse before his marriage 
without perceiving any sign of a return of the disease, he had concluded 
that it had been perfectly eradicated from his system. On further in- 
quiry it is ascertained that his wife had never complained of any sensa- 
tions which might lead even to a suspicion of her having had primary 
symptoms, nor has any appearance taken place in her which can even 
bear a resemblance to secondary symptoms. In a word, both parents 
are pronounced (after the most minute investigation) to be in the en- 
joyment of perfect health. In some cases w r e may discover equivocal 
appearances of disease in the father, yet so faintly resembling syphili- 



INFANTILE SYPHILIS. 707 

tic symptoms that we could not think of considering them as venereal, 
unless our suspicions came to be strengthened by some collateral cir- 
cumstances. 1 Such cases are related also by Mr. Hey, M. Cazenave, and 
Mr. Whitehead. 

Cases of this kind attracted the attention of Dr. Beatty, and he was 
led to infer that they were caused by venereal influence, and were pro- 
bably to be remedied by mercury, and a trial confirmed his conclusions. 
"Several similar cases," he observes, after relating his first case, "oc- 
curred to me from that time with similar success, which I shall pass 
over, as they rest only on my own experience, and shall therefore cpn- 
fine myself to a very few in which I was assisted by M. Colles and Mr. 
Todd, in their capacity of surgeons. In my own book, to which I have 
referred, I find that in August, 1812, I attended the wife of a stay- 
maker, who was delivered of a putrid child in the seventh or eighth month, 
which she said was the third that she had borne dead. I discovered so 
much of venereal affection as to recommend that they should put them- 
selves under the care of some experienced surgeon for the use of mercury. 
They applied to M. Colles, and when she was pregnant in the following 
year, M. Colles told me that they had not continued a sufficient time 
under his direction to satisfy him that they were cured of the venereal 
complaint, which I found to be the case in July, 1813, when I again de- 
livered her of a putrid child in the eighth month. I then declared that 
I never would attend her again until M. Colles told me he was satisfied 
with the result of the mercury used. They again returned to him, and 
fully attending to his directions, in Oct., 1814, I again attended her, 
when she bore a living girl at the full period of gestation. She has had 
several living children since." 2 

Drs. Campbell, 3 Strange, 4 and Egan, 5 Drs. Coley, 6 Snow, Lloyd, "Wade, 
&c, confirm the view taken by Dr. Beatty and M. Colles both as to the 
character, cause, and cure of this class of premature putrid births. M. 
Danyan took a similar view, in a recent discussion at the Academie de 
M6decine, and mentioned that he had succeeded in putting a stop to 
abortion by means of mercury. 7 M. Dubois stated that of the infants 
born dead in hospital some offered evidences of syphilis; others who did 
not, were born of syphilitic patients, and that this was sufficient to justify 
mercurial treatment. 8 Dr. West speaks of abortion being frequent, 
owing to a syphilitic taint, but states that he has never seen an infant 
at birth with evident marks of syphilis. 9 Dr. Condie believes that the 
infant may be affected in utero. 10 

On the other hand, M. Acton, following the French authorities in 
most points, although he admits that syphilis in the mother may cause 
abortion, does not think it frequent. 1, because of its rarity in the vene- 
real hospitals in Paris, and 2, because women so affected often go to the 

1 Pract. Obs. on the Venereal Disease, p. 266. 

2 Trans, of the College of Phys. in Ireland, vol. iv. p. 32 

3 Northern Journal of Medicine, May, 1844. 4 Ibid., Sept., 1844. 
6 Med. Press, March 25, 1851. Dublin Journal, vol. i. p. 335. 

6 Diseases of Children, p. 458. 7 Archives Gen. de Medecine, Aug., 1851. 

8 Gaz. Med. de Paris, 3d series, vol. v. p. 392. 

9 Diseases of Infancy and Childhood, p. 448. 

10 Diseases of Children, p. 564. 



708 INFANTILE SYPHILIS. 

full term, and bring forth healthy children. The first of these state- 
ments is not quite in accordance with general experience, and granting 
the latter to be true, it proves nothing as to the occurrence in question. 
After examining carefully what has been the experience of others, 
and comparing it with my own, I can have no hesitation in concluding 
that syphilitic disease — even when not well marked — in either parent, 
may cause abortion or premature labor, and that in the majority of 
such cases the infant is born dead and putrid, with the cuticle torn and 
easily peeled off. But are we then to conclude that this appearance in 
an-infant is of itself a proof of venereal taint? This is a Very import- 
ant question. We know that when a child is retained in utero for some 
time after death, a process of decomposition takes place, and the result 
is a change of color and a moist loosening of the cuticle. Now if we 
compare the two children born under these circumstances, one of whom 
we know to be born of syphilitic parents, and the other of parents un- 
questionably free from all taint, we shall, I believe, find it quite impos- 
sible to distinguish them, and to decide which is syphilitic and which 
free from the disease. If this be true, we must conclude that no infer- 
ence can be drawn from the appearance of the child alone, but that we 
must also investigate the condition of the parents, remembering that 
very slight evidence of previous disease is sufficient to guide us in the 
treatment of these cases as syphilitic. 

4. It is possible, however, that the infant may be born alive, but so 
weak that it dies in a few hours or days. In such cases the evidence of 
syphilitic disease is often very plain : the skin is loose, bagged, and 
shrivelled, the face has an old withered expression, and there is a cop- 
per-colored eruption about the anus and genitals, and in some cases 
over the whole body. An experienced friend of mine assures me that 
he has seen slight ulceration at the corners of the mouth and margin of 
the anus in such cases. It is right to state that M. Bertin, during ten 
years at the Hopital des VdneViens, had but few cases born with marks 
of syphilis. 

5. Dr. Condie mentions that he has known the infants of diseased 
parents, when born, to present irregular ulcerations or large vesications 
on different parts of the surface, filled with a yellow, turbid, or dark 
colored fluid, and which, upon rupturing, left ulcerations of the skin 
that became quickly covered with thin dark colored crusts, and sur- 
rounded with a dark* red or purplish margin. 1 

M. Gilbert mentions that he has seen vesicles, or papulae, or tuber- 
cles upon the buttocks and genitals, but never the large blisters of pern 
phigus which M. Depaul has described. M. Dubois regards the pem- 
phigus, which is characterized by large blisters filled with a deep yellow 
pus, developed upon the palms of the hands and soles of the feet, and 
with the skin underneath of a bluish or violet color, as being undoubtedly 
syphilitic. 

M. Ricord has frequently noticed syphilitic pemphigus as well as 
smaller vesications. 

John Hunter mentions having seen a child which exhibited venereal 
pustules at birth. 

1 Diseases of Children, p. 566. 



INFANTILE SYPHILIS. 709 

6. Dr. Depaul, of Paris, has recently read a paper on certain changes 
in the lungs of syphilitic children, which had been noticed by Baron, 
Billard, Husson, &c, but which he believes to be peculiar to these cases. 
"In fifteen cases the lungs were more or less studded with small nodules 
composed of dense gray tissue, having a central cavity filled with sero- 
purulent fluid. In most cases the infants had also pemphigus, purulent 
deposits in the thymus gland, or enlargement of the liver, and death 
occurred shortly after birth ; one or both of the parents were known to 
have had syphilis." 1 In the discussion which took place at the Aca- 
dcunie de Medecine, M. Cazeaux, the reporter, regarded the abscesses in 
the lungs as nodules of pneumonia, the pemphigus and abscess of the 
thymus as not necessarily syphilitic. MM. Gebert and Roux agreed 
with him. MM. Moreau and Danyan approved of treating these cases 
as syphilitic. MM. Dubois and Ricord considered that the state of the 
lungs might result from syphilis, but that abscess of the thymus gland 
and the pemphigus were very characteristic of the disease. From the 
equal balance of authorities, it is clear that more observation is neces- 
sary to establish the accuracy of M. Depaul's conclusions. 

II. Syphilis appearing after Birth. — In the greater number of cases 
the symptoms of the disease do not make their appearance until a week 
or more after birth ; nay, it is said that this period may be extended to 
two, three, or six months. 

M. Rizzi states that of fifty-five infants the disease manifested itself 
one month after birth in thirty-three, at the expiration of two months 
in eleven, of three months in four, of four months in four, and in one 
only at the expiration of eight months. 2 

The child is born apparently healthy and well nourished, but after 
a time a number of copper-colored spots appear about the anus or geni- 
tals, and on the inside of the thighs, sometimes spreading over the loins 
and degenerating into ulcers. 

The infant is also attacked by snuffles ; there is an acrid discharge 
from the nostrils, which irritates the parts, and, drying, forms a crust 
which obstructs the nostrils and interferes with respiration. 

The voice is changed in character, it loses its clear tones and becomes 
rough, whispering, and raucous. Superficial ulcers appear at the angles 
of the mouth, sometimes of the mucous membrane, sometimes of the 
skin, which cracks and bleeds. Occasionally the tongue, palate, and 
throat are covered with superficial ulcers. 

Sometimes there is slight muco purulent discharge from the eyes, 
with redness of the tunica conjunctiva. 

If the disease be not arrested, we may have ulcers or fissures in dif- 
ferent folds of the skin, for instance in the folds between the chin and 
throat, in the folds of the thighs, &c. The glands may become enlarged, 
those of the neck and occiput when there is much eruption on the head, 
and others in different parts, but as M. Colles remarks, they are 
very different from buboes in the adult ; there is little active inflamma- 
tion, although some of them occasionally suppurate and ulcerate slowly. 3 

1 Med. Times, July 19, 1851. 2 Gaz. Med. de Paris, Oct. 24, 1846. 

3 Eerton, Mai. Ven., p. 74. 



710 INFANTILE SYPHILIS. 

The child rapidly emaciates, the skin becomes loose and flabby, the 
countenance has a worn, wrinkled and old expression, the strength is 
exhausted, and after an uncertain interval it perishes in a state of ma- 
rasmus. 

The duration varies a good deal: in some cases death takes place in 
a short time, but in others, the majority run on for weeks and months, 
until the child is utterly worn out. 

7. Such is the general course and symptoms of the disease, but from 
these there are many deviations. Often only a portion of these symptoms 
are present, or the order in which they appear may vary. Sometimes 
the snuffles and hoarseness appear first, followed by the eruption about 
the anus and nates, but more generally the reverse. "Now and then 
no other indication of syphilis appears (than the snuffling), but never- 
theless the coryza does not yield until after the child has been brought 
under the influence of mercurial remedies, a fact which would seem to 
show that, although unaccompanied with other signs of venereal taint, 
the snuffles of young infants are produced by that cause." 1 

8. At an advanced stage, pustules may form "about the mouth, espe- 
cially upon the lower lip and chin, which destroy the cutis, and leave 
the surface after they have healed much scarred by their cicatrices." 2 
Or, according to Mr. Acton, " the corner of the child's lips may become 
covered with condylomata, and have a great tendency to crack, forming 
syphilitic psoriasis labialis, or the papules are noticed covered with 
successive scales, which falling off present a raw excoriated surface, and 
are very difficult of cure, as the cicatrices tear whenever the child sucks. 
The tongue is sprinkled over with white spots as large as split peas, and 
have the appearance as if its surface had been touched and whitened 
with caustic; this appearance extends to the throat, and probably to the 
intestines, producing diarrhoea or mucous and sanguinolent discharges. 
The German writers have examined these secretions from the lips and 
mouth, and state that they contain cryptogamic plants; hence their 
belief in the contagiousness of these complaints." 3 M. Berton mentions 
the existence of phlyctenae, which burst, and are followed by ulceration 
of the cutis, which he calls chancre or chancrous ulcer. 4 They may 
occur on the skin, or in the mouth, or about the anus. 

9. The red eruption about the anus and buttocks may not be limited to 
a mere redness, but may assume the form of large moist papules, forming 
condylomata. "These mucous tubercles are very characteristic, in size 
equal to a split pea, sometimes distinct, in other instances confluent, 
elevated above the surrounding skin, which is of the color of boiled ham, 
in parts dry on their surface, and becoming scaly, in other places moist, 
and secreting a fetid discharge, which excoriates the surrounding sur- 
face, producing erythema, eczema and psoriasis of the hands and feet, 
which presently crack and cause great pain to the child, &c." 5 

10. Mr. Hay and Dr. West also mention this peculiar exfoliation of 
the epidermis of the extremities. "The epidermis," the latter observes, 

' Dis. of Infancy and Childhood, p. 448. 2 Ibid., p. 449. Berton, Mai. Ven., p. 46. 

3 Diseases of the Urinary and Generative Organs, p. 612. 

4 Mai. Yen. chez les Nouv.-nes, p. 56. 5 Diseases of the Organs of Generation, p. 612. 



INFANTILE SYPHILIS. 711 

"in some bad cases peels off the hands and feet; it generally becomes 
thickened to a kind of crust, like that which forms on the hands in pso- 
riasis, and then cracking falls off in patches, leaving the skin fissured, 
and sometimes deeply ulcerated at the bend of the wrist, or at the flex- 
ures of the fingers and toes. The new and delicate epidermis in its 
turn undergoes a similar thickening, and becomes detached in the same 
manner, or else it continues white and thin, but shrivelled, and looking 
like the sodden and wrinkled skin of a washerwoman's hand, and peeling 
off in little fragments, leaves the cutis, especially at the tips of the 
fingers and toes, red and bleeding slightly even on the gentlest touch." 1 

11. It is very seldom that severe ulceration takes place, as in the 
adult, by which the bones of the nose or palate are destroyed ; so rare is 
it that M. Colles states that he never met with a case. Dr. West mentions 
that he has seen one instance of destruction of the bony palate, and Mr. 
Acton that he has seen the ossa nasi fall in from ulceration. 

12. M. Berton, in his very valuable work, states that he has observed 
bony tumors and periostosis in infants attacked with syphilis, but they 
are extremely rare. 2 

Causes. — That the disease is always communicated to the infant is, 
of course, undoubted, but the mode may vary. It may be derived either 
from the parents, or from the wet-nurse, or, perhaps, from a dry-nurse. 
A few remarks upon each mode will not be out of place. 

I. Hereditary Syphilis. — a. As we have already seen, an infant may 
be born syphilitic, whose father had the disease some considerable time 
before marriage, but who at the time of marriage and since has been 
either apparently free from the disease, or in whom the symptoms have 
been too slight, or too doubtful to give rise to suspicion. 3 

b. If the father contract syphilis and communicate it to his wife, and 
she conceive, the child will also be contaminated. 

c. The mother and father may both be healthy at the time of im- 
pregnation and for some time after, and yet if either contract syphilis 
the child may be affected. Mr. Porter relates a case in which the father 
became diseased about the third month of his wife's pregnancy, and 
shortly before her confinement several spots resembling button scurvy 
appeared, but nothing more. The child died syphilitic in a week after 
its birth. Mr. Porter remarks : "Now this infant had been begotten in 
April, three months before the father's first contraction of the ailment, 
and must, therefore, have been poisoned by the circulation of the mother 
at a considerable period subsequently. The question is, how did that 
circulation become contaminated, seeing that the father had never a sore 
capable of furnishing a drop of matter, and the mother never a symp- 
tom of any description, until the doubtful one of button scurvy, which 
only appeared a few days before her confinement." 4 Mr. Whitehead in 
his recent work relates analogous cases. 5 He adds that such cases have 
led him to the conclusion that "the semen of a diseased man, deposited 
in the vagina of a healthy woman, by being absorbed, may contami- 

1 Dis. of Infancy and Childhood, p. 450. 2 Mai. Yen. chez les Nouveaux-nes, p. 89. 

3 Whitehead on Hereditary Diseases, p. 213. 

4 Dublin Med. Press, Feb. 17, 1847, p. 110. 
6 On Hereditary Diseases, p. 215. 



712 INFANTILE SYPHILIS. 

nate that woman without the necessary occurrence of a chancre, or any 
open sore secreting matter in either the man or the woman." 

d. But it appears that we may go a step further and conclude that a 
diseased father may transmit the disease to th« infant without the 
mother being affected at all. Some have doubted the possibility of this, 
and some have admitted it with hesitation. M. Bertin and Mr. White- 
head, and M. Vidal de Cassis distinctly maintain this doctrine, and 
quote cases. 1 More recently, Mr. Parker, of Birmingham, has given 
one and Mr. Acton three such cases, in which this appears to have been 
the case, and the latter observes: "We may then, I think, lay it down as a 
rule, that a father laboring under secondary s}''mptoms will contaminate 
the ova which he impregnates, although his wife remain perfectly 
healthy; and it is an error to suppose that a husband laboring under se- 
condary symptoms will first infect his wife, and through her the em- 
bryo." 2 

Dr. West's experience confirms this : he states that "cases are now 
and then met with in which the venereal taint appears to have been de- 
rived entirely from the father, the mother, as far as can be ascertained, 
not having suffered at any time either from primary or secondary symp- 
toms, although she has given birth to an infant affected with all the 
characteristic marks of syphilitic disease." 3 

e. M. Vidal de Cassis goes further still, and states that he saw a case 
in which a husband contracted syphilis, and infected the infant, but not 
the mother. The husband died and the mother married again, and con- 
ceived, but although both parents were apparently healthy, the infant 
was born syphilitic. 4 

II. Derived from the Wet-nurse. — I do not myself feel the least doubt 
that an infant may contract the disease from a wet-nurse affected with 
secondary symptoms, and this opinion, which was held by De Hery, 
Boerhaave, Levret, Hey, and others very eminent, is, I believe, in accord- 
ance with that of the profession in this country at least. 

Mr. Col]es remarks: " There is still another manner in which the infant 
may receive the infection, viz: by sucking a nurse affected with second- 
ary symptoms of syphilis, but I am in doubt whether the diseased nurse 
could infect the child unless she had ulceration of the nipples, and I 
cannot at this moment recollect an instance." 5 

This coincides with the remark of Swediaur, that "in all cases of the 
kind that had come to his knowledge, either the nipples of the nurse were 
infected by syphilitic ulcers in the mouth of the child, or reciprocally, the 
nipples of the nurse being attacked with ulcers, occasioned ulcers of the 
same kind in the mouth, nose, and lips of the child, and thus communi- 
cated to it a general infection." 6 

M. Cazenave, whose eminence as a syphilographer is admitted, has 
met with a number of cases of this kind, and fully believes in this mode 
of transmission. 

Dr. W r est admits the fact, but states that it is an unusual occurrence. 7 

1 Mai. Ve'n., p. 168. 2 Diseases of the Organs of Generation, p. 624. 

3 Dis. of Infancy and Childhood, p. 447. 

4 Traite des Mai. Veneriens, p. 509. 5 On the Venereal Disease, p. 271. 

6 On Syphilis, vol ii. p. 14. 7 Diseases of Infancy and Childhood, p. 447. 



INFANTILE SYPHILIS. 713 

Dr. Egan, -whose experience in the Lock Hospital has been very con- 
siderable, entertains no doubt of this mode of infection, and coincides 
•with M. Colles that ulceration of the nipple is essential. 1 

M. Whitehead maintains this doctrine very strongly, adducing six 
cases, and does not think it necessary that there should be any abrasion 
of the nipple. 2 He has also brought forward evidence from many 
authorities which it would be difficult to gainsay. MM. Cazenave and 
Vidal de Cassis also hold this opinion, the latter believing that the milk 
is the vehicle by which the poison is conveyed to the child, and he cites 
a case of a healthy nurse suckling a healthy child, but who gave suck to 
a syphilitic child, was infected by it, and communicated the disease to 
the first child. I saw a case exactly similar myself, in which the 
casual suckling of a diseased child as an act of kindness, infected both 
the nurse and her proper nursling. 

On the other hand, Mr. Acton does not believe that a diseased nurse 
can communicate the disease to the infant, and he quotes the authority 
of M. Ricord to the same effect. 3 At the same time it must be observed 
that the only argument he used is a negative one, viz: that nurses la- 
boring under syphilis have suckled children without communicating the 
disease. No one doubts this, but it does not prove that a child cannot so 
derive the disease. It may be that none of these nurses had ulcerated 
nipples, and at any rate they may be merely exceptions. 

Very recently M. Cullerier, Jun., has maintained the same opinion, 
and chiefly supported by the same negative proofs. 4 

Some writers, and among the more recent Mr. Lane and Mr. Parker, 
consider that the milk of a diseased nurse is capable of conveying in- 
fection, but this appears to be a doubtful point, although MM. Ricord 
and Vidal seem to admit it; thus coinciding with the opinion of Colom- 
bier, Doublet, and Faguer, and contrary to the opinion of John Hunter. 

M. Bertin gives a case of a child of three years old, who was infected 
by its mother, to show that contact with the lips of an infected person 
may communicate the disease. 5 

in. From the Dry-nurse. — It would seem further to be possible that 
the child may derive the disease from a dry-nurse or an attendant. M. 
Colles relates a case in which the child w 7 as contaminated by the cook, 
and in turn communicated the disease to its dry-nurse, and he remarks : 
" Here, then, are two examples to establish the opinion that secondary 
symptoms are capable of propagating the venereal disease, for in this 
case no suspicion whatever arose in the minds of any of the medical at- 
tendants that the disease of the child had been derived from the parents ; 
indeed the advanced age of the child at the time that it first exhibited 
any signs of the disease, was quite sufficient to remove all doubt or 
suspicion on that head. 6 

Consequences. — Although it is scarcely within the strict limits of this 
work, yet the history of this disease would be so incomplete without some 
notice of the reciprocal influence of a syphilitic infant upon the nurse, 

1 Dublin Journal, N. S., vol. i. p. 334. 2 On Hereditary Diseases, p. 222. 

3 Diseases of the Organs of Generation, p. 628. 

4 Gaz. Med. de Paris, 3e serie, vol. v. p. 892. 

5 Mai. Vener. chez les Nouveaux-nes, p. 27. 6 On the Venereal Disease, p. 275. 



714 INFANTILE SYPHILIS. 

parents, &c, that I am induced to mention briefly the principal conse- 
quences. 

I. M. Ricord believes that a woman quite free from disease herself, but 
carrying a diseased ovum, may become diseased through the medium of 
the foetus, and not by the father. Mr. Acton has seen but one such case. 1 

II. M. Colles notices a curious fact which has been confirmed by Dr. 
Egan and others, viz: that " he had never seen or heard of a single in- 
stance in which a syphilitic infant (although its mouth be ulcerated), 
suckled by its own mother had produced ulceration of her breasts, where- 
as very few instances have occurred where a syphilitic infant had not 
infected a strange hired wet-nurse, and who had previously been in good 
health." 

in. That the child may communicate the infection to the nurse, is, I 
think, generally admitted by the most experienced practitioners, though 
there may be some difference as to the conditions. I lately saw a case 
in which the child derived the disease from one wet-nurse and communi- 
cated it to another, who infected her husband. 

Whether it is essential that there should be a breach of surface in 
the nipple, it is difficult to pronounce absolutely. Swediaur considers it 
essential that there should be ulcers of the mouth. 

Dr. Egan states that a nurse may suckle a diseased infant with per- 
fect safety so long as no abrasion of the cuticle, or ulceration in or 
about the nipple occurs, but that then she is no longer safe, and to this 
rule he has not met with a single exception. 2 

In France Doublet and Bertin have given it as their opinion that a 
child may infect its wet-nurse, and more recently M. Bouchut has pub- 
lished cases to prove it. He states that no one doubts that a child ac- 
quiring syphilis from another person can communicate it to its wet- 
nurse, but the doubt has been whether congenital hereditary syphilis is 
thus transmissible. 3 

Cases of this kind have also been recorded by Lallemand, Drs. King, 
Macnicke and Price. 4 

M. Rizzi, of Milan, not only entertains this opinion, but has furnished 
statistics of the comparative frequency of the symptoms presented by the 
nurse who has contracted specific ulceration of the breast from suckling 
an infected infant. 

On the other hand, some high authorities are doubtful. Mr. Pearson 
states that he has not been able to arrive at absolute conclusions, but 
he does not appear to me to deny the possibility, and some instances he 
mentions seem to support the affirmative. 5 

Trousseau hesitatingly remarks : " Do not observations exist which 
lead to the belief that these local lesions (fissures of the lips) are trans- 
mitted to the nurse by direct inoculation, and produce in her alterations 
of the same kind, sometimes so severe as to destroy the point of the 
nipple." 6 

1 Acton on Disease of Organs of Generation, p. 619. 

2 Dublin Journal, N. S., vol. i. p. 346. 

3 Gaz. Med. de Paris, 3e serie, vol. v. p. 296. 

4 Med. Times, vol. xii. p. 81, 176, 422. 5 MS. Lectures, p. 83. 
6 Archives Gen. de Med., vol. xv. p. 165. 



INFANTILE SYPHILIS. 715 

MM. Ricord and Cullerier, 1 and after him Mr. Acton, entirely deny- 
that venereal can be thus communicated, and he explains or reasons 
away all the instances adduced as either not being specific, or if so, that 
the nurse has contracted syphilis in the ordinary way, but conceals 
or denies it. That a sore mouth (aphthae) in the child, may occasion a 
sore nipple we know, and that this may possibly be mistaken, but 
this really proves nothing against more carefully observed cases, and 
the latter statement is an assumption which puts a stop to all argument, 
and may be applied to disprove almost anything. 

But we do not know that aphthce will occasion a train of constitutional 
affections, as rashes on the skin, ulcers in the throat, ostitis and periostitis, 
which the local infection from the mouth of a syphilitic child causes. 

For myself, I cannot doubt, from the experience of others and my 
own, that a diseased child may infect the wet-nurse. I am not prepared 
to say positively whether abrasion of the surface is essential, although 
I think it probable. 

The peculiar train of symptoms to which this infection gives rise have 
been graphically described by Mr. Colles. "In some days, or at least 
in a very few weeks, after the nurse has observed the venereal symptoms 
appear on the child, her sufferings commence. She is at first affected 
with what she terms a sore nipple. On inquiry it will be found that 
one or two pimples or pustules have appeared near the nipple; these 
soon degenerate into an ulcer, which presents the characters of a se- 
condary, rather than a primary venereal ulcer; this becomes exquisitely 
sensitive. A slight enlargement and tenderness of some of the axillary 
glands quickly follow, but these glands do not betray any strong tendency 
to run into suppuration ; on the contrary, I must say that I have not 
seen one single instance in which this occurred. In two or three weeks 
more the nurse complains of sore throat, or of an eruption, and not un- 
frequently these two symptoms appear almost simultaneously. An eye 
accustomed to view the secondary symptoms of syphilis does not dis- 
cover any difference between these and the venereal sore throat and 
eruption which follow a primary ulcer in the adult. The pudenda of 
the infected nurse are very generally beset with small raised ulcers 
which discharge copiously — these are to be seen, perhaps, in every case 
where a general eruption of the skin exists, but not unfrequently they 
may be found accompanying the superficial white ulceration of the 
throat, where no general eruption exists, and when the skin remains 
free from a general venereal eruption. I have occasionally seen venereal 
iritis also attack the nurse. What other symptoms might arise, or 
what course the disease might follow if longer unattended to, I cannot 
pretend to say, because I have scarcely ever seen any case in which the 
course of symptoms might not have been disturbed and deranged by the 
exhibition of mercury. But many of those affected nurses to whom 
mercury was administered became affected with very obstinate ulcera- 
tions of the throat, and with pains of the bones and joints." 2 

In M. Rizzi's able report of the Milan Hospital it is stated that of 100 
women with chancres in the breast, from impure lactation, or in the 

1 Gazette Med. de Paris, 3e serie, vol. v. p. 892. 2 On the Venereal Disease, p. 233 



716 INFANTILE SYPHILIS. 

mouth and throat, derived from contact with an infected infant; 34 had 
tubercles of the vulva, 19 syphilitic angina, 2 iritis, 14 tubercles of the 
vulva and angina simultaneously, 5 tubercles of the vulva, and others 
disseminated over other parts of the body, 6 tubercles of the vulva, 
angina, tubercles of the skin and iritis, and 19 no secondary symptoms. 1 

IV. But the evil may not stop here ; the nurse thus infected may com- 
municate the disease to her husband; for according to W. Colles, and no 
higher authority do I know, he "may become affected with ulcerations 
on the genitals, and these in a short time are attended by superficial 
ulcerations of the throat and mouth. If we have an opportunity of 
examining the nurse at the time her husband first complained of ulcer- 
ation of the genitals, we shall find a greater or smaller number of small, 
raspberry like, moist, raised excrescences, or as some term them, ulcers, 
on the genitals, and inside of the top of the thighs of the nurse, and 
this while there is no eruption on the general surface of the skin," &c. 

This opinion is confirmed by the great experience of M. Rizzi in the 
manner already referred to. 

V. In this melancholy history there is yet a further step ; not only- 
may the infant infect the nurse, and through her her husband, but it is 
possible that the contamination may be extended to any, or all the 
members of her family, and in the following manner: "If we suppose, 
as frequently happens, that the child is suckled in the house of the wet- 
nurse, and that she has a numerous family of children, to one of her 
daughters (more particularly) is assigned the care of dressing and carry- 
ing about this infant — this is the child that first suffers from the con- 
tamination. The whole family being completely ignorant of the nature 
of this disease, the girl sleeps as usual with the rest of her brothers and 
sisters — for among the lower order of Irish, that family is considered to 
be in comfortable circumstances, which can afford a separate bed for the 
parents, while all their numerous progeny are huddled together in an- 
other bed — the discharge from the ulcers about the anus and vagina 
coming in contact with one of her brothers or sisters will produce a 
similar ulcer on those persons, and in this manner, obviously, a number 
of the family contract the disease." 2 Mr. Colles adduces cases in sup- 
port of this view. 

Diagnosis. — In many cases the diagnosis is environed with greater 
difficulties than the treatment, for although an experienced eye will in 
general arrive at a correct conclusion, there are cases in which it is 
almost impossible to pronounce positively. No caution can be too great 
where such serious consequences are involved. 

I. Congenital Syphilis. — a. In such cases as Dr. Beatty has de- 
scribed, and in which the foetus is born dead and putrid, I have already 
stated my belief that the appearance of the child, the altered color, the 
loose cuticle, &c, are not sufficient alone to enable us to pronounce the 
case to be venereal; but if we can make out any trace of syphilis, in 
either parent, or even the occurrence of the disease in the father before 
marriage, I think that then the repeated births of dead and putrid chil- 
dren may fairly be supposed to arise from this cause. 

* On the Venereal Disease, p. 290. 2 Gaz. Med. de Paris. Oct. 24, 1846. 



INFANTILE SYPHILIS. 717 

h. But the child may be born alive, and die almost immediately; ex- 
hibiting an eruption of papules, vesicles, or pemphigus. Even in these 
cases we should, perhaps, not be satisfied without some evidence to show 
that one parent had had some form of venereal. Ulcerations at the 
angles of the mouth, or about the anus, are strong additional evidence 
of a syphilitic taint, though not absolute proof. 

M. Dubois, 1 and more recently, M. Depaul, have laid some stress upon 
abscess of the thymus gland, as characteristic of syphilis in new-born 
children, and the latter has further supposed a species of abscess of the 
lungs as equally valuable, but I fear that we have not as yet a sufficient 
number of observations to establish the fact. 

II. Syphilis developed after Birth.- — Dr. Bird remarks that " there 
is seldom any real difficulty in the diagnosis of these cases when once 
the practitioner has learned to recognize them. The characteristic 
snuffling will often enable him to recognize the existence of disease even 
before he has confirmed his opinion by visual examination. The puck- 
ered mouth, the position of the very characteristic eruption around the lips 
and anus, in addition to the peculiar varnished and fissured appearance 
of the parts from which the scales have faded, will seldom, if ever, fail 
to convert a suspicion of the true nature of the disease into positive cer- 
tainty." 2 Doubtless, as in other diseases, when we have a concurrence 
of different symptoms, the case may be clear enough, but this does not 
prove that any one or two symptoms are pathognomonic. In the care- 
ful estimate of these single symptoms, and in the judgment formed of 
them collectively will consist the accuracy of our diagnosis. "We some- 
times meet with an infant having numerous spots of moist button scurvy 
about the anus, genitals and inside of the thighs. Should other mem- 
bers also, of the family, exhibit similar symptoms, we are not in much 
danger of mistaking them for syphilis, because a slight attention to the 
history of each case, and to the marked difference in the more grown 
subjects, between button scurvy and syphilis will alone enable us to de- 
cide; but .where the infant is the only member of the family so affected, 
we are liable to commit a mistake, if we form a hasty opinion. A little 
attention will enable us to decide correctly, for although the anus and 
external organs of generation may present appearances pretty closely 
resembling those of syphilis, yet we shall be able to distinguish them 
from the latter, by observing that they are raised above the surface, 
that they are most distinct and distant from each other, while those 
in syphilis begin with a number of blotches pretty thickly set, then en- 
large a little and then ulcerate, without being at any time raised above 
the sound skin. An eruption of copper-colored spots is not unfre- 
quently seen about the anus and genitals of infants, otherwise perfectly 
healthy — these Ave must not hastily pronounce to be venereal ; they are 
sometimes caused by inattention to cleanliness, and sometimes by a disor- 
dered state of the alimentary canal. But these spots remain the single 
symptom; this disease is not found to make progress; it does not show 
itself in the mouth or throat, or on other parts of the body, and it soon 

1 Gazette He'd, cle Paris, 8e serie, vol. v. p. 892. 

2 Guy's Hospital Reports, 2e serie, April, 1845. 



718 INFANTILE SYPHILIS. 

yields to persevering cleanliness, and a regulated condition of the ali- 
mentary canal. The anus of infants is subject to fissure, which begin- 
ning on the skin, extends in upon the mucous membrane of the rectum. 
We know that such is not venereal when we find it remain a single soli- 
tary symptom; this yields to black-wash and ordinary local treatment. 
A superficial ulcer is sometimes found on the rugous skin of the anus; 
generally with one part of the edge rather deep, the rest of the edge 
thin. This ulcer is not very painful, it is indolent, and sometimes con- 
tinues for many weeks or months, the general health of the child re- 
maining unimpaired. Strict attention to keeping this ulcer constantly 
covered with some stimulating application will effect its cure in a very 
moderate space of time." 1 

M. Trousseau states that he depends greatly in forming his diagnosis 
upon the peculiar yellow color of the skin, which he thinks of more value 
than the copper color of the eruption. He places great value on the 
cracks which appear on the hands and feet, and considers them rarely 
deceptive when present, which he admits is not always the case; and 
lastly, the combination of several syphilitic symptoms occurring at the 
same time. 2 

I think, then, that we may conclude that although one symptom may 
have a greater value than another, yet that any one alone is not suffi- 
cient to decide the question ; nay, that each symptom has its analogue 
in non-syphilitic cases; but that when several coexist, and in proportion 
to their number, we shall find no difficulty in arriving at a correct con- 
clusion. Thus if there be a spreading copper-colored eruption, a yellow 
skin, ulceration of the angles of the mouth and anus, snuffles, fissures of the 
skin, &c, the case may justly be assumed to be syphilitic, and, of course, 
if due care be taken, the history and condition of the parents or wet- 
nurse will form a valuable help to us in forming our opinion. 3 

Prognosis. — I have already mentioned that generally, if remedies be 
not applied, the child dies after a shorter or longer interval, sometimes 
in a few days. 

But if proper treatment be applied early, and the child be not very 
deeply contaminated, we may hope to save a considerable number. 

A statistical paper was recently read by Mr. Acton to the Med.- 
Chir. Society, June 9th, from which it appears that the greatest mor- 
tality from syphilis is in children under one year. 4 

Treatment. — I shall first speak of the treatment of those cases where 
repeated abortions of dead children have occurred, and I must differ en- 
tirely from MM. Gibert, Roux, &c, who, being doubtful as to the cause 
of the abortion, object to the use of mercury. Even if I doubted, or in 
cases in which I may still doubt whether there be any venereal taint, I 
should still be disposed to try mercury, simply on the ground of ex- 
perience, that in similar cases it has succeeded in preventing the death 
and premature expulsion of the foetus. But believing, as I am com- 
pelled to do, that syphilis is the cause of this accident in many cases, I 
have no hesitation in saying that we ought to give our patient the benefit 

1 Colles on Venereal Diseases, p. 275. 2 Archives Gen. de Me'd., vol. xv. p. 149. 

3 Acton on Dis. of Organs of Generation, p. 640. 4 Banking's Abstract, vol. iv. p. 293. 



INFANTILE SYPHILIS. 719 

of our experience. Both parents ought to go through a regular course 
of mercury, and to sustain from cohabitation until the medical man is 
satisfied with its effects. We have the testimony of Dr. Beatty, M. 
Colles, Dr. Egan, and MM. Moreau, Danyan, Dubois, &c, as to its suc- 
cess. 

M. Levret considered that it was quite possible to cure an infant in 
utero, but the difficulty would be to know that it was affected. M. Bertin 
agrees that the mother may be cured of syphilis during pregnancy, and 
that the child will be born healthy. 

Dr. Egan mentions that he succeeded in producing ptyalism in a case 
of this kind, in the fifth month of pregnancy, and saved the child. 1 

Then, as to the treatment of syphilis in any form in infants after 
birth, although doubtless many of the symptoms may be cured without 
mercury, yet I do not think it would either be satisfactory or complete. 
We may give hyd. c. creta gr. i. ter in die, three times a day, or a frac- 
tion of a grain of calomel as frequently, according to the age of the 
child, and this should be continued until the symptoms disappear. If 
the bowels are too much moved or irritated, we may combine the p. 
creta co. or the p. creta co. cm. opio, so as to restrain them. 

Mercurial inunction has been very long in use, and is of great value ; 
it was used by Levret, Fabre, &c, and probably Sir B. Brodie's mode 
of applying it by means of a flannel bandage smeared with the ung. 
hyd. will be found the most convenient. 

Mr. Pearson recommends that a scruple of mercurial ointment should 
be rubbed on the child's body nearly every day for five or six weeks. 

Mr. Acton states that he never gives mercury to infants, but depends 
upon its external application, by means of this mercurial belt, and fre- 
quent warm baths. 

Of course, though we must bring the system fully under the influence 
of the mercury, we do not expect the usual symptoms of it in ptyalism. 
Mercurial purging we may have, and in most cases it is not a bad test, 
but the best is the gradual abatement of the disease, and if there be 
ulceration of the mouth, even the diminution of the salivation which 
already existed. The disappearance of the symptoms is not always a 
proof that the disease is entirely eradicated, as we find relapses not un- 
common ; however, they will be relieved, as before, by mercury. 

The external ulcerations will require local treatment ; black wash is 
one of the best, and if any one proves obstinate we may advantageously 
change the black wash for a dressing of dilute citrine ointment, or 
washed with a weak solution of nitrate of silver, or sulphate of copper. 2 

"I am not acquainted," says M. Colles, " with any remedy which can 
be with advantage applied to the ulcers of the lips, palate, and throat ; 
the very act of applying anything to them irritates the ulcers, and 
causes them to bleed, so that I have imagined that they did fully as 
much harm as good, and on that account have long since relinquished 
their use altogether. I am not aware of any local treatment for the 
swelling of the enlarged lymphatic glands ; they yield readily to the 

1 Med. Press, March 2G, 1851, p. 195. 

2 Condie on Diseases of Children, p. 567. 



720 INFANTILE SYPHILIS. 

constitutional influence of mercury. The slight purulent discharge of 
the eyes is benefited by a mildly astringent collyrium." 1 

All authorities are agreed that the wet-nurse should be brought under 
the influence of mercury, and some, Levret, Fabre, Bertin, &c, have 
asserted that the child may be sufficiently affected by remedies given to 
the nurse; but this appears doubtful. M. Colles saw cases in which this 
failed, and he is decidedly of opinion that the cure of the infant will be 
more speedy as well as more certain if mercury be given to it at the 
same time as to the nurse. 

After the syphilitic symptoms have disappeared, unless the child's 
health be completely restored, some tonic may be given, cascarilla, sar- 
saparilla, columba, or bark, the syrup of cinchona being the pleasantest 
form for young children. 

Dr. West speaks well of minute doses of iodide of potash in sarsapa- 
rilla, if there be no irritation of the bowels, but if the syphilitic cachexia 
be well marked, the syrup of the iodide of iron. 

1 On the Venereal Disease, p. 283. 



INDEX 



AUTHORS AND WORKS REFERRED TO IN THIS VOLUME. 



Abercrombie, J., M. D. Pathological and Practical Researches on Diseases of the 

Brain, &c: Amer. edit., Philada., 1843. 
Abernethy, J. On Diseases of the Brain. 
Acton. Diseases of the Urinary and Generative Organs. 
Albert, Dr. Hufeland's Journal der Practische Heilkunde, Aug. 1830. 
Albert, Mich., M. D. De Tussi Infantili Epidemica : Halle, 1728. 
Alcock, Dr. Dublin Medical Journal. 

Alcock, Thos., M. D. Lectures on Surgery : London, 1830. 
Alderson, Dr. Med.-Chir. Transactions, Pathology of Hooping-Cough, 1830. 
Aldis, Dr. Medical Gazette. 
Aliprendi. Diet, of Practical Medicine. 
Alison, Scott, M. D. On Dropsy following Scarlet Fever: London Journal of 

Medicine, No. 3, 1849. 
Andral, M. Mai. de l'Abdomen, in Clinique Medicale. 
Andry and Auvity. Encycl. Method, de Med., vol. v. 
Armstrong, Geo., M. D. An Account of the Diseases most incident to Children : 

London, 1783. 
Ashburner, J. On Dentition and some coincident Disorders: London, 1834. 
Ashwell, Samuel, M. D. Diseases of Females : Amer. edit., Philada., Lea and 

Blanchard, 1847. 
Ashwell. On Prolonged Lactation. 
Audiganne. Gazette Medicale. 

Baffos, M. Cooper's Surgical Dictionary. 

Bailly and Legendre, MM. Archives Gen^rales de Medecine, January and Feb- 
ruary, 1844: Nouvelles researches sur quelques Maladies des Poumons. 

Bard, S., M. D. Transactions of the American Philosophical Society. 

Barnard, Dr. Lancet. 

Baron. Diet, de Med., art. Cephalsematome. 

Baron, Ch. De la Pleuresie dans l'Enfance: These, Paris, 1841. 

Barrier, F. Traite Pratique des Maladies de l'Enfance: 2d edit., Paris, 1845. 

Barrin. Mai. de l'Enfance. 

Barthez, M. Archives Gen. de MM., July, 1838. 

Bateman, Dr. Edinburgh Med. & Surg. Journal. 

Bateman, Thos., M. D. Practical Synopsis of Cutaneous Diseases : London, 1817. 

Battersby, Dr. Dublin Journal, Nov. 1847. On Hare-lip. 

Battersby's Essay. Ed. Med. and Surg. Journal, Jan. 1851. 

Baudelocque. Lancette Francaise, 1837, art. des Accouchemens. 

Baumes, J. B. T. Traite de l'Icterus ou Jaunisse des Enfans de naissance : 
Paris, 1805. 

Bedor, M. Dictionnaire de Medecine de Fabre. 
46 



722 INDEX OF AUTHORS AND WORKS REFERRED TO. 

Bennett, J. H., M. D. Des Veg6taux qui croissent sur l'Homme et sur les Ani- 

maux vivans, 1847. 
Bennett, Henry, M. D. Lancet, December 30, 1843. 
Bernhardt. Preuss. Med. Zeitung. 
Berard, M. Manuel d'Anatomie. 

Berton, E. A. J. Traite des Maladies des Enfans : 2d edit., Paris, 1832. 
Berton. Mai. Ven. 

Berzelius, J. J. Traite de Chimie : Paris, 1829. 
Biett ; in Abrege Pratique sur les Maladies de la Peau, by Cazenave & Schedel : 

Paris, 1828. Amer. edit., Philada., 1829. 
Bigbie. Ed. Monthly Journal, Jan. 1852. 
Bigger, Dr. Dublin Medical Press. 
Billard, C. M. Traite des Maladies des Enfans Nouveaux-nes : Paris, 1837. 

Amer. edit., by Jas. Stewart : New York, 1845. 
Blache. Dictionnaire des Sciences Med. 
Blache. Archives Generates. 
Bland and Stroehlin. Med.-Chir., April, 1839. 
Blancard, S. Collect. Phys. Med. : cent. 1, obs. 75. 
Blane, Sir Gilbert. Lectures on the Structure and Physiology of the Bones : 

London Lancet. 
Blaud de Beaucaire. Nouvelles recherches sur la Laryngo-trach6ite : Paris, 1824. 
Bouchut, E. Manuel Pratique des Maladies des Enfans Nouveaux-nes et des 

Enfans a la mamelle : Paris, 1845. 
Bouillaud, J. Traite des Maladies du Coeur: Paris, 1835. 
Brachet. Sur les Convulsions, 1824. 
Breen. Pract. Midwifery. 

Brendel. Prog, de Tussi Convuls. : Gotting, 1747. 
Breschet, G. Dictionnaire des Sciences Medicales. 
Bretonneau, P. Des Inflam. Speciales du Tissu Muqueux et en particulier de la 

Diphtherite: Paris, 1826. 
Brewerton, Mr. Ed. Med. and Surg. Journal. 
Brunet, F. Memoire sur la Pneumonie lobulaire, in Journal Hebdomadaire des 

Sciences Medicales, 1833. 
Buffon. Histoire Naturelle. 
Bull, Thos., M. D. Maternal Management of Children. Amer. edit., Philada., 

1849. 
Burgess, Dr. Eruptions of the Face, Head, and Hands. 
Burrows, Dr. Medico-Chirurgical Transactions. 
Bush of Berlin, and Levy of Copenhagen. Brit, and For. Med. Rev. 
Butter, W. A Treatise on Kink-cough : London, 1773. 
Butter, Dr. Treatise on Infantile Remittent Fever: London, 1782. 

Campbell, Dr. A. B. Northern Journal of Medicine. 

Capuron. Vol. iii. 

Carmichael, Mr. Transac. of the Association of Physicians of Ireland. 

Caspar. Wochenschrift. 

Cazenave, P. L. A. Lemons sur les Maladies de la Peau. 

Charcelay, M. Recueil de la Soc. Med. d'Indre et Loire. 

Chaussier. Bull, de la Faculte de Med., 1821. 

Chelius, Max. Jos. Handbuch der Chirurgie : Heidelberg, 1829. Amer. edit., 
translated and edited by South : Philada., Lea & Blanchard, 1848. 

Cheyne, Dr. J. Essay 2, On Bowel Complaints. Essays on the Diseases of Child- 
ren : Edinburgh, 1801. 

Cheyne, Dr. J. On Acute Hydrocephalus, 2d edit. : Dublin, 1809. 

Cheyne, Dr. J. Pathology of the Larynx and Bronchia : Edinburgh, 1809. 

Chomel & Bouillaud, MM. Clinique, vol. ii. 

Churchill, F., M. D. Theory and Practice of Midwifery. Amer. edit., by R. M. 
Huston, M. D. : Philada., Lea & Blanchard, 1848. 

Clark, Sir James. On Consumption. Amer. edit., Philada., 1835. 

Clark, James. On Yellow Fever : London, 1798. 

Clarke, Dr. John. Commentaries on Diseases of Children : London, 1798. 

Clarke, Dr. Joseph. Transactions of the Royal Irish Academy. 



INDEX OF AUTHORS AND WORKS REFERRED TO. 723 

Cogswell, Dr. N. Y. Med. Repository. 

Coley, John Milman. Practical Treatise on the Diseases of Children : London, 

1846. 
Colles. Dublin Hospital Report, vol. i. 
Colles. Practical Observations on the Venereal Disease. 
Collins, Dr. Practical Treatise on Midwifery. Amer. edit., Philada. 
Condie, D. F., M. D. On Diseases of Children: 4th edit., Philada., 1855. 
Constant, M. Gazette des Hopitaux. 
Constant, M. Gazette Medicale. 
Combe, Dr. A. On the Management of Infancy and Childhood. Amer. edit., by 

J. Bell, M. D. : 1840. 
Cooper, S. Surgical Dictionary. 
Copland, Jas. Dictionary of Medicine. 
Cormaok, Dr. Rose. London Journal of Medicine. 
Corrigan's Lecture. Dublin Hospital Gazette, April, 1845. 
Cotugno, D. De Sedibus Variolarum : Neapoli, 1775. 
Crisp, Mr. London Medical Gazette, Dec. 1846. On Infantile Pleurisy. 
Cruveilhier, J. Anatomie Pathologique du Corps Humain : Paris, 1832. 
Cullen, W., M. D. First Lines of the Practice of Physic. Amer. edit., 

Philada., 1822. 
dimming, T. Observations on Peripneumonia of Children, in Transactions of 

Assoc, of College of Physicians in Ireland, vol. v. 

Danyau. Archiv. Gen. de Med., Aug. 1851. 

Danz, F. G. Versuch einer Allgemeine Geschichte des Keichhustens: Marbourg, 

1791. 
Darwall. Plain Instructions for the Management of Children. 
Davis, Dr. D. On Acute Hydrocephalus : London, 1840. 
Dease, W. Observations on Midwifery: Dublin, 1785. 
De Cassis, Vidal. Traite des Mai. Veneriens. 
Deleurye. La Mere selon l'Ordre de la Nature. 
Dendy, W. C. Portraits of the Diseases of the Scalp. 
Denis, R. S. Recherches Anatomiques et Physiologiques sur quelques Maladies 

desEnfans: Paris, 1824. 
Deschamps. Journal de Medecine. 
De Paul. Med. Times, July, 1851. 
d'Espine, Marc. Hufeland's Journal. 

Desruelles, H. M. J. Traite Theorique et Pratique du Croup: Paris, 1822. 
Desruelles, H. M. J. Traite de la Coqueluche : Paris, 1827. 
Dessault, P. Traite des Mai. Chirurg. : Paris, 1795. 
Dewees, W. P., M. D. A Treatise on the Physical and Medical Treatment of 

Children : 9th edit., Philada., 1847. 
Dieffenbach, M. Abscessus Capitis Sang. Neonatorum, in Rust's Handbuch der 

Chirurgie : Berlin, 1830. 
Doherty. Dublin Journal, vol. xxv. 
Dubois. Gazette Med. de Paris, 31 series, vol. 5. 
Dubois, M. Nouv. Diet, de Medecine. 
Duges, A. Recherches sur les Maladies les plus importantes etles moins connues 

des Nouveaux-nes: Paris, 1821. 
Duges, A. Diet, de Med. et de Chir. Pratiques, art. Gynascologie. 
Duges, A. Manuel d'Accouchemens. 

Duncan, Dr. Dublin Quarterly Journal of Med. Science: 1845. On the Epi- 
demic Ulceration of the Gums in Children. 
Dungan. Archiv. Gen. de Med., Aug. 1851. 
Dunglison, Dr. Robley. On Diseases of the Stomach and Bowels in Children : 

London, 1824. 
Dupuytren, Le Baron. Leqons orales de Clinique Chirurgicale : Paris, 1832-4. 

Eberle, John, M. D. On Diseases of Children : Cincinnati, 1833. 

Edwards, W. F. S. On the Influence of Physical Agents upon Life : American 

edition, Philadelphia, 1838. 
Egan. Med. Press, 1851. 



724 INDEX OF AUTHORS AND WORKS REFERRED TO. 

Els'asser, Dr. Die Magenerweichung der S'auglinge : Stuttgard, 1846. 
Engelmann, M. Archives Generates de Medecine, June, 1838. On the Treat- 
ment of Hydrencephalus by Compression. 

Fabre, M. Bibliotheque de Medecine Pratique. 

Fabre. Med. Chir. Review, July, 1851. 

Fedran, M. Memoires de l'Acad. de Chirurgie. 

Ferguson, Prof. Transactions of the Royal Medical and Surgical Society. 

Ferguson, Prof. London Journal of Medicine, 1849. 

Ferrand. Memoires de l'Acad. de Chir., vol. v. 

Ferriar, S. John. Medical Histories and Reflexions: Manchester, 1795. 

Ferrus, M. Dictionnaire de Medecine. 

Fisher, Dr. On Cerebral Auscultation, in American Journal of the Medical 

Sciences, March, 1838, and October, 1843. 
Fliess. Journal ftlr Kinderkrankheiten, June and July, 1849 ; Lond. Journal of 

Med., Jan. 1850. 
Fleischmann. Die Entziindung. 

Fleischmann. De Vitiis Congenitis circa Thoracem et Abdomen. 
Fleming, Dr. Dublin Medical Journal. 
Fortin, M. Cephalaematome sous pericran. 
Fournet. Recherches Clin, sur l'Oscultation et sur la Premiere Periode de la 

Phthisie. 
Francis, Dr. New York Medical and Physical Journal. 
Fried. Extrait. des Theses de Haller. 
Friedleben. Archiv. fur Physiolog. Heilkunde, 1847. 
Friedleben & Fleisch, MM. Zeitschrift fur Rationelle Medicin, 1846. On the 

Pathology of the Intestinal Mucous Membrane in Young Infants. 
Furlong. Edin. Med. and Surg. Journal. 
Fyfe, Dr. Provincial Medical and Surgical Journal, June 16, 1847. 

Gardien. Traite des Accouchemens. 

Gairdner and Baly. Ed. Monthly Journal, Nov. 1850. 

Gendrin, A. N. Translation of Abercrombie. 

Gerhard, Dr. W. W. Lobular Pneumonia of Children: in American Journal of 

the Medical Sciences, 1834. 
Geoghegan, Dr. Medical Press, March 8, 1848. 

Gintrac, E. Observations et Recherches sur la Cyanose : Paris, 1824. 
Gintrac & Breschet, MM. Repertoire Gen. d' Anatomic 
Gooch, R., M. D. Diseases of Women. 
Good J. M., M. D. Study of Medicine : American edition, by Dr. Doane : New 

' York, 1843. 
Golis. Treatise on the Hydrocephalus Acutus, translated by R. Gooch, M. D. : 

London, 1821. 
Golis. Practische Abhandlungen. 

Graetzer, J. Die Krankheiten des Fotus : Breslau, 1837. 

Graves Dr. R.. J. Clinical Lectures : second American edition, Philada., 1848. 
Green, Dr. Lancet. 
Green Dr. Med.-Chir. Transactions, vol. xxv. On Tubercle of the Brain in 

Children. 
Gregory, Dr. G. On Eruptive Fevers. 

Grisolle, A. Traite Pratique de la Pneumonie aux differens ages : Paris, 1841. 
Gruner. Var. Antiq. ab Arab. 
Guersent. Dictionnaire de Medecine, art. Croup. 
Guibert, H. Recherches sur la Croup et la Coqueluche : Paris, 1824. 
Gumprecht. Medico-Chirurgical Transactions. 

Hache, M. Maladies des Enfans. 
Haine, M. Ranking's Abstract. 

Hall, Marshall, Dr. Diseases and Derangements of the Nervous System : Lon- 
don, 1836. 
Haller, A. De Monstris : Gotting. 1751. 
Hamilton, Dr. Jas., Jr. On Diseases of Infants : London, 1809. 



INDEX OF AUTHORS AND WORKS REFERRED TO. 725 

liana of Illinois. Am. Med. Journal, Oct. 1850 and 1851. 

Harris, Dr. W. De Morbis Acutis Infantum : London, 1705. 

Hasse's Pathological Anatomy, Sydenham Society. 

Hawkins, F. Bisset. Elements of Medical Statistics : London, 1829. 

Hayes, Pliny. Braithwaite's Retrospect, vol. ix. 

Hegewisch, Dr. Rust's Magazin. 

Heim, M. Hufeland's Journal. On Revaccination. 

Henke, A. A. Handbuch der Kinderkrankheiten : Frankfort, 1621. 

Henle's Zeitschrift, vol. iii. 

Herrich & Popps. Der Plotzlicben Tod aus inneren Ursachen. 

Hess, Prof. Ranking's Abstract. 

Heyfelder. Beobachtungen liber der Krankheiten der Neugebornen, 1822. 

Hevfelder. Studien in Gebiete der Heilwissenschaft. 

Hillary, W., M. D. On the Smallpox: London, 1735. 

Hillary. Maladies des Nouveaux-nes. 

Hird, M. Lancet, Dec. 1846. 

Hoere, G. F. De Tumore Cranii recens natorum sanguineo, &c. : Berlin, 1824. 

Home, Dr. Medical Facts and Experiments, 1759. 

Hood, P. Practical Observations on the Diseases most fatal to Children, &c. : 

London, 1845. 
Hope, J., M. D. On Diseases of the Heart : second American edition, Philada., 

1846. 
Horner, W. E., M. D. American Journal of the Medical Sciences, 1829, 1831. 

On the Pathology of Cholera Infantum and Infantile Convulsions. 
Hughes, Dr. Guy's Hospital Reports, No. 3 and 4, 1844. 
Hutchinson, A. C. Surgical Dictionary. 

Innes. Surgical Dictionary, art. Spina Bifida. 
Isenflamm. Archives Generales de Medecine. 

Jackson, S., M. D. (of Northumberland). American Journal of the Medical 

Sciences, August, 1834. On Gangroanopsis. 
Jacques. Journ. Gen. de Med., vol. xxix. 

Jaeger. Hufeland's Journal, 1811. On the Softening of the Stomach in Children. 
Jahrbericht liber die Leistungen des Unentzeldlichen Kinderkranken Insti- 

tuts, &c. 
Jervis. Journal Gen. de Medecine. 
Joerg. Die Foetusleunge in Neubornen Kinder. 

Johnson, C. On Hooping-Cough, in Cyclopaedia of Practical Medicine. 
Joy, Dr. Cyclopaedia of Medicine, art. Fever, Infantile Remittent. 

Keilmann. Prodrom. Act. Havn. 

Kennedy, Dr. II. Some account of the Epidemic of Scarlatina which prevailed 

in Dublin from 1834 to 1842 : Dublin, 1843. 
Kennedy, Evory. Dublin Journal, vol. vi. 

Kerkring, Thos. Spicilegium Anat., obs. 57 : Amsterdam, 1670. 
Kirkes. Med. Gazette, 1850. 
Kitsell. Am. Journ., Jan. 1850. 
Krukenberg. Jahrbucher des Ambulatorischen Klinik zu Halle, 1824, 2 vols. 

Labatt, Dr. On Cow-pox. 

Labatt. Edin. Med. and Surgical Journal. 

Laennec, R. T. H. De. 1' Auscultation Mediate: 3me edit., Paris, 1831. 

Lallemand, Prof. On Softening of the Brain. 

Latham, P., M. D. Lectures on Diseases of the Heart: Amer. edit., Philada., 1848. 

Lee, C. A., M. D. New York Medical and Physical Journal. 

Legendre. M. Recherches, &c, sur quelques Maladies de l'Enfance. Paris, 

1846. 
Legendre. Am. Journal of Med. Sciences. 

Leger, V. Essai sur la Pneumonie des Enfans: These, Paris, 1823. 
Lelut. Archives Generales de Medecine. 
Ley, Dr. Hugh. On Laryngismus Stridulus : Lond., 1836. 



726 INDEX OE AUTHORS AND WORKS REFERRED TO. 

Linnfeus, C. Diss. Exanth. xiv. ; in Amoenitat. 

Lindsley, Dr. American Journal of the Medical Sciences, vol. xxiv. 1839. On 

Cholera Infantum. 
Lion, Dr. Ranking's Abstract. 

Liston, R. Practical Surgery: Amer. edit., Philada., 1848. 

Louis, P. C. A. Memoires et Recherches Anatomico-pathologiques : Paris, 1826. 
Louis, P. C. A. Recherches Anat. Path, sur le Croup considere chez l'Adulte : 

Paris, 1826. 
Luidsly, Harvey. American Med. Journal, April, 1851. 

Magendie. Sur le Fluide Cephalorachidienne. 

Malespini. Archives Generales de Medecine. 

Malgaigne, M. BulL de Therap., 1840. 

Marcus, A. F. Der Keichhusten : Lips., 1816. 

Marcus, A. F. Traite de la Coqueluche, 1816: trad, par M. Jacques. 

Marley, Miles. On Diseases of Children: London, 1830. 

Marsh, Sir H. Dublin Hospital Reports, vols. iii. v. 

Martin. Rec. Period, de la Soc. de Med. de Paris : April, 1840. 

Marthey. Seance pub. de la Soc. Roy. de Paris. 

Matuszinski, M. Gazette Med., 1837. 

Maunsell. On Diseases of Children. 

Mauran. Philada. Medical Journal, Aug. 1827. 

Mauthner. Die Kranken des Geherns und R'uchenmarks bei Kindern : Vienna, 

1844. 
Mauthner. British and Foreign Review, April, 1846. 
Mayne, Dr. Dublin Quart. Journal of Med. Science, Mav, 1844, and August, 

1846. 
McClean, Mr. Visit to St. Kilda. 
Mechel, J. F. Manuel d'Anatomie Generale, &c. : Paris, 1825. Amer. edit., by 

Dr. Doane: Philada., 1832. 
Meigs, J. Forsyth, M. D. Practical Treatise on Diseases of Children : Philad., 

1854. 
Meine, Dr. Osteomalacia et ejus in partum actione. 
Meissner, Henke, and Heyfelder. Archives, 3d series, vol. v. 
Michaelis. Ueber eine eigene Art. von Blutgeschwiilsten. 

Michaelis. London Medical Transactions, de Angina polyposa: Gottingen, 1778. 
Miller. Obs. on Asthma and Hooping-Cough : London, 1769. 
Mills, Dr. On Hydrocephalus, Transactions of the King and Queen's College of 

Physicians in Ireland, vol. v. 
Moncrieff, in A. Monro, tertius, Morbid Anatomy of the Brain. 
Mondiere. L'Experience, June 25. On Intra-arachnoidean Hemorrhage. 
Mone. Dublin Journal, vol. vii. 
Monro, Dr. On the Morbid Anatomy of the Brain, vol. i. : Lond and Edin., 

1827. 
Monro, A. L. On the Smallpox: Edinburgh, 1818. 
Montgomery, Dr. Dublin Journal, vol. ix. On the Sudden Death of Children 

from Enlargement of the Thymus Gland. 
Morgagni, J. B. De Sed. et Causis Morb. Epist. : Paris edit., 1820-'23. 
Morton, E., M. D. Observations on the Healthy and Diseased Condition of the 

Breast, Milk, &c. : London, 1831. 
Moscati & Pallette. De Abscessu Sang. Capit. Mediol. 
Moss, W. On the Management and Nursing of Children : London, 1782. 
Munchmayer. Schmidt's Jahrbucher, vol. xxv., 1840. 

Naegele. Erfahrungen und Abhandlungen. 

Naegele, II. F. Lehrbuch der Geburtshulfe : Mainz, 1843. 

Naegele. Art. des Accouchemens. 

Nairne. Lond. Journ. of Med., Jan. 1851. 

Neligan, Dr. Eruptive Diseases of the Scalp. 

Neligan, Dr. Medicines and their Uses: Amer. edit. 

Neumeister of Arneburg. Journal fur Kinderkrankheiten, Jan. and Feb. 1851. 

Neunham. British Rec. of Obst. Med., No. 6. 






INDEX OF AUTHORS AND WORKS REFERRED TO. 727 

Nevins. Lond. Med. Gazette, Jan. 1850. 

North, John. Practical Observations on Convulsions of Infants : London, 1826. 

O'Ferrall, Dr. Dublin Hospital Gazette. 

Ollivier, C. P. Traite de la Mo'elle Epiniere, et de ses Maladies: Paris, 1824. 

Orfila. In Grcetzer, Krankheiten des Fiitus. 

Osiander. Ilandbuch der Entbindungskunst. 

Paget, John. On the Congenital Malformations of the Heart: Edinburgh Medical 

Journal, vol. xxxvi. 
Paldam, V. H. L. Der Stickhusten : Halle, 1805. 
Palletta. Memoir read before the Institute at Milan. 
Palmer, Dr. Medico-Chirurgical Journal, 1816. 
Panarola. Obs. Med. Pentecost. 
Panure of Copenhagen. Mode of Propagation of Measles. Ed. Monthly Journ. 

of Med., 1851. 
Papavoine. Journal des Progres, 1830. On Tubercles and Convulsions in 

Infants. 
Parent-Duchatelet and Martinet. Recherches sur l'lnnammation de l'Arach- 

noide Cerebrale et Spinale : Paris, 1819. 
Parrish, Jos., M. D. On Infantile Convulsions arising from Spasm of Intestines : 

N. Amer. Med. and Surgical Journal, 1827. 
Pearson, Mr. Med.-Chir. Transactions. 
Peddie. Edinburgh Monthly Journal, Aug. 1848. 
Pemberton. On various Diseases of the Abdominal Viscera. 
Penada, G. Memoria Sulla Tussa Convulsiva : Verona, 1815. 
Pereira, Jonathan. A Treatise on Food and Diet. Amer. edit., by C. A. Lee: 

New York, 1843. 
Peirson, M. S. Lectures. 

Petz, Abney, and Baudelocque. North Am. Med. Journal. 
Petzholdt, M. ; Archives Gen. de Medecine. 
Piet. Thesis, 1836. 

Piet. American Journal of Med. Sciences. 
Pigne, M. Journal Hebdomadaire. 
Planque. Bibliotheque de Medecine, vol. iii. 

Piorry, P. A. De 1'Irritation Encephalique des Enfans : Paris, 1823. 
Porter, W. II. Surgical Pathology of the Larynx and Trachea : Dublin, 1837. 
Porter. Dublin Medical Press. 
Price. Med. Times, vol. xii. 
Purefoy, Dr. Dublin Journal, May, 1846. 

Quetelet, A. Sur l'Homme, et le Developpement de ses Facultes: English edit., 
Edinburgh, 1842. 

Ramel, Journal de Medecine, de Chirurgie, et de Pharmacie, 1778. 

Ramisch. De Gastromalacia et Gastropathia Infantum : Prague, 1824. 

Ramsbotham. London Med. and Phys. Journal. 

Rau. Handbuch der Kinderkrankheiten. 

Raulin. De la Conservation des Enfans. 

Recherches sur Plusieurs Maladies. 

Reece, Dr. Med.-Chir. Review. 

Rees. Atelectasis Pulmonum. 

Report of the Royal Infirmai-y for 1846. 

Reports of the Registrar-General. 

Reveille-Parise, M. Gazette Medicale. 

Richerand, le Baron. Nosographie Chirurgicale: Paris, 1815. 

Rigby, E., M. D. A System of Midwifery. Amer. edit,, Philadelphia, 1840. 

Rilliet and Barthez. Traite Clinique et Pratique des Maladies des Enfans : Paris, 

1843. 
Ringland, Dr. Dublin Journal, July, 1841, vol. xis. 
Riverius. Obs. Commun : London, 1840. 
Rizzi. Gazette Med. de Paris. 



728 INDEX OF AUTHORS AND "WORKS REFERRED TO. 

Roe, Geo. H. Treatise on the Nature and Treatment of Hooping-Cougli : London, 

1838. 
Roeser. Diet, of Medicine. 

Rogers, Dr. Jos. An Essay on Epidemic Diseases: Dublin, 1734. 
Roman, M. Ann. de la Soc. Med. Prat. de. Montpellier. 
Romberg, Dr. Wocbenschrift fur die gesammt. Heilkunde, 1833 : liber Magen, 

erweichung. 
Rosenvon Rosenstein. On the Diseases of Children. English edit., London, 

1776. 
Rostan, M. Dictionnaire de Medecine. 
Roux. De Carditide Exsudativa. 

Rudolphi. Abhandlungen der Kb'nigl. Acad, zu Berlin. 
Rufz, F. Journal des Connoissances Medico-Chirurgicales, 1835. 
Rufz. Arch. Gen. de Med., 1834. 
Rufz. American Journ. Med. Sciences. 
Rusasus. De Extract. Foetus. 

Rush, B., M. D. Med. Obs. and Inq.: Phila., 1800. On Dropsy of the Brain. 
Rutty, John. On the Weather, Seasons, and Prevailing Diseases of Dublin: 

Dublin, 1770. 
Ruysch, Acrell, and Isenflaum. Arch. Gen. de Med., vol. iv. 

Saillant. Memoires de la Soc. de Medecine. 

Salleneuve, M. Mem. de FAcad. de Chirurgie. 

Salter. Med.-Chir. Transactions,, vol. x. 

Sanson. Dictionnaire de Med. et de Chir. Pratique, art. Hernie. 

Sargent, Jos. Am. Journal of Med. Sciences, July, 1849. 

Sauvage. Nosolog. Method. 

Schmidtmann, Albert. Observationes Medicae, vol. ii. 

Schneider, Dr. Edinburgh Med. and Surg. Journal. 

Scholler. Medicinische Zeitung. 

Schultz. M. N. C. Dec. 1, An. 6, 7. 

Schundtmann. Albers de Trachaaitide. 

Schwartz, L. W. Siebold's Journal, B. 7. 

Schweinger. Uber Tuberculose als die gewohnlichste Ursache der Hydrocephalus 

acutus. 
Segerus. M. N. C. Dec. 1, An. 3, obs. 160, p. 291. 
Seitz, Dr. Ranking's Abstract. 

Sentin. Beitrage zur ausiibenden Arzneiwissenshaft. 
Sestie & Cazalis, MM. Bull, de la Soc. Anat. : 1832. 
Sherwood, Dr. Medical Repository. 
Siebold, J. A. Journal fur Geburtshlilfe. 
Simpson, J. Y. Edinburgh Med. and Surg. Journal. 

Sims. American Journal of Med. Sciences, April, 1846, July and Oct. 1848. 
Smith, H , M. D. On Hydrocephalus. 
Stewart, J. On Diseases of Children : New York, 1841. 
St. Hilaire, Geoffroy Isidore. Histoire Generale et Particuliere des Anomalies de 

l'Organisation, &c: Paris, 1832. 
St. Hilaire. Art. Anencephalie, in Diet, de Med. et de Chir. Prat., vol ii. 
Stoeber. Clin, des Mai. des Enfants de la Faculte de Strasburg, 1841. 
Stokes. Diseases of the Chest. 
Stokes, Win., M. D. Diseases of the Chest: American edition, Philadelphia, 

1844. 
Strange. Northern Journ. of Med., Sept. 1844. 
Sturve. On the Physical Management of Children : Berlin, 1776. 
Suiron, M. Ranking's Abstract. 
Swagemann. Ontleed. Heilkund. Yerhandl. 
Swediaur. On Syphilis. 
Sydenham. Opera Universa : London, 1726. 

Taupin. Journal des Connois. Med-Chir., 1830-1840. On Typhoid Fever in 

Infants. 
Taupin. Recherches sur le Diagnostique des Mai. de la Poitrine ehez les Enfans. 



INDEX OF AUTHORS AND WORKS REFERRED TO. 729 

Thompson. London Medical Repository, Jan., 1814. 

Thore, M. Archives Generates de Medecine, 1846. De la Peritonite chez les 

Nouveaux-nes. 
Todd. Cyclopedia of Anatomy and Physiology, Part xxv. 
Todo, Dr. Jas. Medical Gazette, Dec. 25, 1846. 
Tonnelle. Maladies des Enfans. 
Tretis, Dr. Medical and Physical Journal. 
Troccon. Sur la Maladie connue sous le nom d'Endurcissement du Tissue Cellu- 

laire, 1814. 
Trousseau and Lasegne. Archives Gen. de Medecine, vol. xxvi. 
Trousseau, M. Journal des Connois. Med.-Chir. 

Underwood, Mich., M. D. A Treatise on the Diseases of Children : American 

edition, by J. Bell, M. D. : Philadelphia, 1842. 
Uwins, David. Med. and Phys. Journal, August, 1816, and Sept., 1819. 

Valentine, Louis. Sur le Croup: Paris, 1812. 

Valleix, F. L. J. Clinique des Maladies des Enfans Nouveaux-nes : Paris, 1838. 

Vauthier, Dr. Arch. G6n. de Medecine, May, 1848. 

Velpeau, A. A. L. M. Nouveaux Elements de Medecine Operatoire : Paris, 

1832. 
Velpeau, A. A. L. M. Traite des Accouch. : edit, de Bruxelles. 
Veron. Recherches des Maladies des Nouveaux-nes : Paris, 1821. 
Veron. Seance de PAcad. Roy. de Med., June 28, 1825. 

Waddington, Mr. Lancet, June 21, 1845. 

Walther, M. Ranking's Abstract. 

Watson. Lectures on Principles and Practice of Phvsic, by Condie : Philada., 
Lea & Blanchard, 1847. 

Watt, R. Treatise on the History and Treatment of Chin-cough: Glasgow, 1813. 

Webster, D. London Med. and Phys. Journal. 

Weisberg. Dissertatio de Prseternaturali et raro intestini recti cum vesica urina- 
ria coalitu, &c, 1779. 

West, Chas., M. D. Lectures on the Diseases of Infancy and Childhood : Philada., 
Lea & Blanchard, 1855. 

Whitehead. On Hereditary Diseases. 

Whitlock, Nicholl, Dr. Practical Remarks on Disordered States of the Cerebral 
Structures, occurring in Infants : London, 1821. 

Whitney. Am. Journ. Med. Sciences, Oct. 1843. 

Whytt. On Nervous Diseases. 

Wicke. Analeckten der Kinderkrankheiten. 

Wilde. Report upon the Tables of Death. 

Wilkshire. Lond. Journ. of Medicine, June, 1850. 

Willan. Diseases of the Skin. 

Willey, Dr. American Medical Repository. 

Williams, C. J. B. Pathology and Diagnosis of Diseases of the Chest : Amer. 
edit., Philada., Haswell, Barrington & Haswell, 1839. 

Williamson. Lond. Lancet, June, 1853. 

Willis. Opera Omnia: Amst., 1682. De Morb. Convulsiv. Puerorum, &c. 

Wilson, Mr. Philosophical Transactions. 

Wooton, Dr. Transactions of The College of Physicians of Philada. 

Wright. British American Journal, April, 1850. 

Wrisbey, H. A. Descriptio Anat. Embryon., 1764. 

Wunderlich. Handbiich des Pathologie unci Therapie. 

Zeller, Ch. Thesis de Cephalasmatomate : Heidelberg, 1822. 



INDEX. 



Abscess of the brain, 184 

between the pharynx and the spine, 481 
diagnosis of, 482 
symptoms of, 481 
treatment of, 482 
Air, importance of pure, 58 
Angina, pseudo-membranosa, 468 
Anus, imperforate, 413 
Apoplexy, 195 

causes of, 200 

cerebral, 197 

diagnosis, 200 

meningeal, 196 
Aphthse, 437 

causes of, 440 

pathology of, 438 

prognosis of, 440 

treatment of, 440 
Artificial feeding, 46 
Asthma, thymic, 315 
Atelectasis pulrnonum, 292 



Bathing, importance of, 52 
Brain, abscess of, 184 

absence of, 72 

congestion of, 195 

hypertrophy and induration of, 178 

inflammation of, 176 

tubercles or tumor, 186 

pathology of tubercles of, 189 
Bronchitis, 300 

diagnosis, 312 

prognosis of, 312 

pathology, 305 

modifications and complications, 307 

treatment, 312 
Bronchitis, chronic, 304 



Calorification, state of it in infancy, 29 
Cancrum oris, 446 
Caput succedaneum, 82 



Carnification of the lung. 329 

Cathartics for the removal of the meconium, 

35 
Cephalhematoma, sub-aponeurotic, 84 

sub-pericranial, 85 

sub-cranial, 87 

pathology of, 88 

termination of, 89 

treatment of, 89 
Cerebro-spinal system, diseases of, 71 
Chicken-pox, 645 
Cholera infantum, 457 
Chorea, 102 

causes of, 108 

complications, 105 

diagnosis of, 109 

pathology of, 106 

prognosis of, 110 

symptoms of, 103 

treatment of, 110 
Cleanliness, importance of, 52 
Cleft palate, 410 
Clothing of the infant, 56 
Colitis, 521 

Condition of the foetus in utero, 23 
Congestion of the brain, 195 
Convulsions, 71 

sympathetic and symptomatic, 114 

causes of, 115 

diagnosis of, 126 

prognosis of, 127 

symptoms of, 119 

treatment of, 127 
Coqueluche, 229 
Coryza, 213 

causes of, 214 

treatment of, 215 
Cowpox, vaccinia, 668 
Cranium, fractures of the, 82 
Croup, 259 

causes of, 272 

complications of, 273 

pathology of, 267 

prophylactic treatment of, 292 

stages of, 261 

symptoms of, 261 

tracheotomy of, 286 

treatment of, 279 
Cyanosis, 377 

pathology of, 381 



732 



INDEX. 



Cynanche parotidea, 464 
tonsillaris, 460 
trachealis, 259 



D. 



Dance of St. Guy, 102 
Dentition, 416 
Diarrhoea, 508 

varieties of, 504 . 
Digestive system, diseases of, 405 
Diphtherite, 468 
Disease, intra-uterine, 213 
Dress, changes in, 57 

materials of, 56 
Dry nursing, fatal effects, 37 
Dysentery, 527 

causes of, 526 

diagnosis of, 522 

morbid anatomy of, 525 

treatment of, 526 
Dysentery, chronic, 528 



Eczema, 572 

Edema of the cellular tissue, 677 

complications, 681 
Encephalitis, 176 

causes of, 177 

diagnosis of, 177 

symptoms of, 176 

treatment of, 178 
Encephalocele, 73 

diagnosis of, 74 

treatment of, 75 
Endocarditis, 397 

diagnosis of, 403 

morbid anatomy of, 402 

prognosis of, 403 

results of, 400 

symptoms of, 397 

treatment of, 403 
Enteritis, 509 

causes of, 513 

diagnosis of, 515 

treatment of, 515 
Epistaxis, 215 

treatment of, 216 
Exercise, importance of, during childhood, 
59 

precautions in regard to, 59 



F. 

Fever, infantile remittent, 
causes of, 691 
complications of, 689 
diagnosis of, 692 
pathology of, 690 
prognosis of, 693 
symptoms of, 685 
treatment of, 693 



685 



Foetus, source of disease in the, 25 
Food of infancy and childhood, 40 

of neAvborn infant, 87 
Flannel, importance of in the clothing 

children, 56 
Fractures of the cranium, 82 



Gangrene of the mouth, 446 

causes of, 455 

diagnosis of, 457 

pathology of, 452 

prognosis of, 457 

symptoms of, 446 

treatment of, 457 
Gangrenous ulceration of the pharynx, 475 
Gastric fever (see Fever, infantile remit- 
tent), 614 
Gastritis, 496 

causes of, 500 

diagnosis, 501 

morbid auatomy, 498 

symptoms of, 496 

treatment of, 501 
Glottis, spasm of the, 216 
Growth of the infant, 29 



H. 



Hare-lip, 406 

treatment of, 406 
Heart, diseases of, 374 

anomalies as to the number of, 376 
malformations of, 876 
Helminthiasis, 530 
Hernia cerebri, 73 
Herpes, 571 
Hooping-cough, 229 
Hydrocephalus, 71 
acute, 134 

causes of, 148 
diagnosis, 151 
historical notice of, 135 
pathology of, 145 
prognosis of, 153 
stages of, 136 
terminations of, 153 
treatment of, 154 
chronic, 160 

causes of, 169 
diagnosis of, 169 
historical notice of, 172 
pathology of, 166 
symptoms of, 162 
treatment of, 169 
Hydrorachitis, 75 

operations for, by puncture, 81 
Hypertrophy of the brain, 178 
causes of, 181 
diagnosis of, 181 
pathology of, 181 
prognosis of, 182 



INDEX. 



'33 



Hypertrophy — continued. 

treatment of, 182 
Hydrenceplialoid, 175 



Imperforate anus, 413 
Impetigo, 576 
Incontinence of milk, 38 
Indigestion, 488 

causes of, 493 

diagnosis of, 493 

morbid anatomy, 492 

symptoms of, 488 

treatment of, 493 
Infancy, effects of poverty upon the mor- 
tality in, 22 
Infancy and childhood, food of, 40 

statistics of mortality in, 19 
Infant, management of at birth, 32 
Infantile remittent fever, 685 
Infants, peculiarities of the nervous system 
in, 29 

peculiarities of the digestive system, 29 

times of feeding newborn, 40 
Inflammation of the pericardium, 385 

of the pleura, 341 
Influenza, 308 
Intestinal worms, 530 

causes of, 534 

treatment of, 535 

varieties of, 530 
Intra-uterine diseases, 405 
Irritations arising from severe dentition, 
421 

of the nervous system, 90 



J. 

Jaundice, 538 

causes of, 540 
pathology of, 539 
prognosis of, 540 
treatment of, 541 



Lancing the gums, 421 
Laryngismus stridulus, 216 
Ligature of the cord, 34 
Light, importance of in infancy, 65 
Liver, enlargement of, 541 
Lobar pneumonia, 316 

duration of, 319 

physical signs of, 318 
Lobular pneumonia, 319 

duration of, 322 

physical signs of, 320 
Lungs, gangrene of, 330 

inflammation of, 315 



M. 



Malformation of the nipple, effects of, 38 
Management of the infant at birth, 32 
Measles, 589 

causes of, 604 

complications of, 597 

diagnosis of, 606 

modifications of, 593 

morbid anatomy of, 603 

prognosis of, 607 

symptoms of, 590 

treatment of, 608 
Medicine, use of in infancy, 65 
Meningitis, tubercular, 205 
Milk, analysis of different kinds, 46 

effects of organic diseases upon, 39 

influence of mental emotions upon, 39 

influence of menstruation upon, 39 
Mortality in infancy, statistics, 19 

effects of poverty upon, 22 
Mouth, inflammation of the, 426 
Muguet, 427 

diagnosis of, 435 

pathology of, 428 

prognosis of, 435 

symptoms of, 427 

treatment of, 435 
Mumps, 464 



N. 



Nervous irritation, 90 

causes of, 92 

symptoms of, 91 

treatment of, 93 
Nine-day fits, 94 

causes of, 95 

symptoms of, 95 

treatment of, 100 
Nursery, location and furniture, 66 

regulation of the, 67 

temperature of, 67 
Nurses, 67 
Nurse, domestic qualities of, 68 

duties of the, 67 



Parotitis, 464 

causes of, 466 
symptoms of, 464 
treatment of, 466 

Pericarditis, 385 
causes of, 393 
morbid anatomy of, 392 
symptoms of, 387 
treatment of, 395 

Peritonitis, 554 

diagnosis of, 557 
morbid anatomy of, 556 
prognosis of, 557 
terminations of, 563 
treatment of, 565 



734 



INDEX. 



Pertussis, 229 

causes of, 246 

complications of, 236 

diagnosis of, 247 

pathology of, 241 

prognosis of, 248 

symptoms of, 281 

treatment of, 249 
Pharyngitis pseudo-membranous, 468 

causes of, 472 

complications of, 472 

diagnosis of, 473 

morbid anatomy of, 471 

prognosis of, 473 

symptoms of, 468 

treatment of, 474 
Pityriasis, 569 
Pleuritis, 341 

causes of, 349 

diagnosis of, 351 

morbid anatomy of, 347 

prognosis of, 351 

symptoms of, 342 

treatment of, 352 
Pneumonia, 315 

complications of, 325 

diagnosis of, 327 

lobar, 316 

lobular, 319 

primary, 324 

prognosis of, 338 

secondary, 324 

treatment of, 338 
Porrigo, 578 

favosa, 583 

scutulata, 578 
Prurigo, 568 
Putrid sore throat, 475 

causes of, 480 

diagnosis of, 480 

morbid anatomy of, 478 

prognosis of, 480 

symptoms of, 476 

treatment of, 481 



Quinsy, 460 



R. 



Ramollissement of the brain, 183 

diagnosis of, 184 

pathology of, 184 
Respiration in the infant, 29 
Roseola, 570 
Rubeola, 589 
Rupea, 574 



Scald head, 578 
Scalp, abscess of the, ■ 
Scarlatina, 610 



Scarlatina anginosa, 616 
Scarlet fever, 610 

causes of, 635 

complications of, 620 

diagnosis of, 637 
Scarlatina maligna, treatment of, 641 
Scarlatina, pathology of, 633 

periods of, 618 

prognosis of, 638 

prophylaxis of, 644 

treatment of, 639 
Scleroma, 677 
Senses, progressive education of the, in 

infant, 81 
Serum, Breschet's analysis of, 167 
Shower bath, tonic effects of, 52 
Skin, diseases of, 567 
Skull, absence of the, 72 
Sleep of infants, 63 
Smallpox (see Variola), 649 
Spasm of the glottis, 216 

causes of, 226 

diagnosis of, 226 

pathology of, 220 

prognosis of, 227 

symptoms of, 218 

treatment of, 227 
Spleen, enlargement of, 544 
Spina bifida, 75 

Spinal marrow, tubercles of, 186 
Spoon feeding, 46 
Staphyloraphe, 410 

State of muscular action in the infant, 31 
Stomach, diseases of the, 483 

inflammation of the, 496 

pathological changes in the mucous 
membrane of the, 498 
Softening of the stomach, 500 

brain, 183 
Stomatitis, 426 

treatment of, 441 
Strophulus, 567 
St. Vitus' dance, 102 
Syphilis, 705 

in infants at birth, 706 

the cause of abortion, or premature 
labor, 707 

appearances of child at birth, 708 

appearing after birth, 709 

hereditary, 711 

symptoms, 710 

derived from the wet nurse, 712 
dry nurse, 713 

consequences, 714 

diagnosis, 716 

congenital, 716 

developed after birth, 717 

prognosis, 718 

treatment, 718 
Swine-pox, 645 



Thrush, 437 



INDEX. 



70/ 



186 



Thymic asthma, 315 

Tonsillitis, 460 
causes of, 462 
diagnosis of, 462 
symptoms of, 460 
treatment of, 462 

Trismus nascentium, 94 

Tubercular meningitis, 205 
symptoms of, 205 

Tubercles of the brain, 
causes of, 190 
diagnosis of, 191 
treatment of, 192 
of the spinal 

treatment of, 192 

Typhoid fever, 695 

modifications of, 697 



Ulcerated sore mouth, 44: 
pathology of, 443 
symptoms of, 442 
treatment of, 444 



Vaccinia (history of), 669 
course of, 669 
diagnosis of, 675 

modifications and irregularities of, 670 
mode of operating, 675 



Varicella, 645 

diagnosis of, 648 
modifications of, 647 
symptoms of, 646 
treatment of, 649 
Varieties of food and modes of administi 

tion, 40 
Variola, 649 

causes of, 662 
complications of, 657 
diagnosis of, 664 
modifications of, 655 
pathology of, 661 
period of incubation, 650 
invasion, 650 
eruption, 651 
suppuration, 652 
desiccation, 654 
prognosis of, 654 
symptoms of, 650 
treatment of, 665 
Varioloid, 657 
Vernix caseosa, 33 



W. 

Washing infants, mode of, 33 

Walking, precautions in teaching, I 

Water stroke, 145 

Weaning, 44 

Weaning brash, 490 

Worm fever (see Fever, remittent). 



THE END. 



